TELEHEALTH ASSESSMENT

Prior to starting your first appointment, it is important to ensure that telehealth services are appropriate for your needs. Please take a few moments to complete this questionnaire if you would prefer to schedule directly (which you can do here) and not have a free 15 minute consultation call.

First Name

Last Name

Address

Who is your insurance carrier if you have it?

Message

Please check the boxes below to confirm which of the following are accurate as they are important considerations when deciding if virtual care is a a viable option for you. Please select as many as apply.

I have access to a strong internet connection for video appointments and the ability to ensure privacy and safety at the location(s) I plan to have my appointmet.

I am comfortable and capable of using online based services for all aspects of my mental healthcare, including but not limited to video visits, email communication, paperwork completion, sevice payment, etc.

I am a resident of (and will be physically present at the time of our appointment in) either NC, VA, DC, MD, PA, or WV.

I understand that if a significant barrier to care delivery is identified before or during our first appointment, treatment may end and referrals will be provided to more accessible providers.

Thank you for reaching out. I will be following up with you shortly by email. If you are in crisis and your safety is at risk, please call 911 or go to your local hospital.