Luminello

This form helps prospective patients/clients and clinicians connect more efficiently and explore whether the requested relationship will be a good fit. As clinician skill sets, availability, and financial policies vary, this form helps ensure you find the right clinician for your needs.

If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911 or go to your closest emergency room.

This request is not an emergency or urgent matter. I wish to proceed

Clinical Info

Please tell us about the person for whom treatment is being requested

Patient/client first name *

Patient/client last name *

Patient/client gender *

Date of birth *

My relationship to the patient/client *

My phone number *

How were you referred to me? *

Check all of the following that are applicable: *

In therapy now

On psychiatric medication now

In the hospital now or recently

In therapy in the past

Taken psychiatric medication in the past

Attempted suicide in the past

Hospitalized for psychiatric reasons in the past

Known neurologic or genetic disorder

None of the above

Home address:
*

Patient's Date of Birth: *

Current medications (name and dose): *

Is substance use (alcohol or drugs) also an issue? Please list current and past substance use. *

Scheduling Info

Are there any times that would NOT work for scheduling an appointment? *

Are you able to attend appointments Monday-Thursday between 9am-2pm? I do not offer evening or weekend hours. *

Are you interested in telehealth or in person appointments? *

Do you have any other scheduling limitations? *

Payment Info

What will be the primary payment method? *

Private Pay

Blue Cross Blue Shield

If your insurance plan is accepted by the clinician, what is the policy ID number? For private pay, enter 'n/a'. *

This space is for any additional information that you would like to share: *

Alisha Jaquith, MD

In Practice Since

Location

Clinical Info

Scheduling Info

Payment Info

Alisha Jaquith, MD

In Practice Since

Location

Clinical Info

Scheduling Info

Payment Info

Just checking...