Request Appointment | Geode Health
We need a few more details before requesting your appointment
Process for making an appointment:
1.
Fill out and submit the initial New Patient Form below.
2.
Within 5 minutes of submitting the form, you will receive a link via text & email to provide detailed information for your appointment request. Please complete this within 5 days of receiving the link.
3.
A referral coordinator will reach out to schedule you with a provider.
* A professional referral from another psychiatrist, primary care provider, or counselor may be required. Our referral coordinators will assist you in getting the referrals. Please note, we will match you with the best available provider for your care.
* All new patient appointments will require a credit card on file OR $100 appointment deposit that will be applied to your copay, deductible, or coinsurance at your first and second visit.
Patient Name
Patient Date of Birth
Patient Email
Patient Phone
Patient Gender
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Payment
I'm using Insurance
You may still owe a copay
Insurance...
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What is the reason for your visit? (Required)
It’s helpful for your provider to know what you would like to get out of your session
Is supervision or aid required to attend the visit?
Risk taking or dangerous behavior?
Medications
Do any of the following apply to you?
Anticipating treatment with controlled substances (e.g. stimulants such as Adderall, or benzodiazepines like Xanax, Klonopin etc)
Seeking addiction treatment (e.g. Detox, Buprenorphine/Suboxone, Psychotherapy for addiction, etc.)
In need of clinician to sign Disability, FMLA, or legal paperwork
Psychiatric and/or substance hospitalization/rehabilitation in last 2 weeks
Suicide attempt or active thoughts of self-harm in the last 2 weeks
None of the above
How did you hear about us?
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*By clicking Book My Session, I acknowledge that I have read and understand the Terms & Conditions.
*By providing my mobile number, I hereby authorize Geode Health (including all associated medical practices) to contact me by mobile phone, including phone calls and texts. I understand that text messages are not sent in a secured (encrypted) format. Third parties may attempt to or actually access, use and disclose information transmitted by Geode Health to my cellular phone via text message.
*I understand that emails are unencrypted and that there is some risk that information included in unencrypted messages, including email messages, may be intercepted or received by unintended third parties and/or stored or archived by our service providers and system operators.
If you are in crisis and are in need of immediate support, please call the National Suicide Prevention Lifeline (Lifeline) at 1-800-273-TALK (8255), or text the Crisis Text Line (text HELLO to 741741).
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