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PRE-CONSULTATION SCREENING

Thank you for your interest in Selective Psychiatry. This brief questionnaire helps us determine whether this practice is likely to be a good fit for your needs and whether we may be able to work well together.​

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Please take a few minutes to answer the questions thoughtfully and honestly. Your responses will help guide the next steps and ensure that your consultation is as productive as possible.

 

All information you provide is confidential and protected by HIPAA and our Privacy Policy.

We appreciate your trust and look forward to learning more about you.​

State of Residence
Are you enrolled in Medicare?
Yes
No
What are you hoping to receive from this practice?
Are you currently experiencing any of the following?
Are you currently under the care of a psychiatrist or prescribing provider?
Yes
No
Do you currently use any of the following substances regularly?
Are you comfortable with membership structure (24–48 hour response, no emergency coverage)?
Yes
No
This is a direct-pay model. Are you comfortable with this?
Yes
No
Are you seeking an ongoing prescribing relationship?
Yes
No
Are you comfortable with membership investment?
Yes
No
I would like more information
I understand that Selective Psychiatry:

Please check all boxes to confirm agreement.

Then click "Submit Form"







Care is provided only to individuals located in states where the clinician holds active licensure: AZ, CA, CO, ID, MO, MT, and WA

Selective Psychiatry is not an emergency service.


If you are experiencing a psychiatric emergency, call 911 or 988.

© 2021 - 2026 Selective Psychiatry.

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