Psychiatry Consultation Request

Request for New Patient Psychiatry Consultation

I acknowledge that this form is for psychiatry (medication) appointment requests ONLY. I understand that WellSpring tends to stay full and may not have openings available. Submitting this form does not guarantee an appointment. Under no circumstances should this form be used for emergency situations. If this is an emergency please call 911 immediately or visit the local emergency room. *

I Agree

* Indicates required field

I understand that the Psychiatry Department accepts ONLY Anthem, BCBS, Carefirst, Medicare, and Tricare Insurance plans, and does not accept Medicaid. I will be using the following to pay for services: *

Will you be using any Medicaid plan to pay for your prescriptions at the pharmacy? *

Yes No

Contact Name *

Age of Client *

Email *

Phone Number for Contact *

Contact is: *

Self (Adult seeking services) Legal Guardian of a child seeking services Healthcare Provider seeking referral

I understand that WellSpring may contact me by phone, and may leave a voicemail at the number provided. IF YOUR VOICEMAIL IS FULL, YOU WILL NOT RECEIVE OUR MESSAGES. *

I understand

Who referred you for Psychiatry? (e.g., Psychology Today, Another Provider, etc.) *

Thank you for your request! If an appointment may be available, we will call you to schedule within 5 business days. Please be aware that, while we try to respond to every request, due to the high volume of requests, we may not be able to respond in cases where no appointments are available. Thank you for your understanding!

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