TKG

Clinicians

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 *

Select Gender Female Male Agender Androgyne Androgynous Bigender Cis Cisgender Cis Female Cis Male Cis Man Cis Woman Cisgender Female Cisgender Male Cisgender Man Cisgender Woman Female to Male FTM Gender Fluid Gender Nonconforming Gender Questioning Gender Variant Genderqueer Intersex Male to Female MTF Neither Neutrois Non-binary Other Pangender Trans Trans* Trans Female Trans* Female Trans Male Trans* Male Trans Man Trans* Man Trans Person Trans* Person Trans Woman Trans* Woman Transfeminine Transgender Transgender Female Transgender Male Transgender Man Transgender Person Transgender Woman Transmasculine Transsexual Transsexual Female Transsexual Male Transsexual Man Transsexual Person Transsexual Woman Two-Spirit

Date of birth *

My relationship to the patient/client *

Myself Father Mother Other

My phone number *

Cell Home Fax Work Other

How were you referred to me? *

What are the main issues? Check all that apply: *

Anger

Anxiety

Attentional difficulties

Autism spectrum concerns

Behavioral problems

Defiance/oppositionality

Depression

Eating/body image issues

Educational difficulties

Moodiness

Other - please specify

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

What kind of care is being sought? *

Medication

Psychotherapy

Both

Not sure

Other - please specify

What medications are you currently taking? Please list the name, dosage and directions. Please note efficacy and tolerance for your current medication regiment. *

If you are currently on medications, who is currently prescribing your current medications? Why are looking to find another prescriber? *

Do you have a current therapist or prescribing physician? If so, who? *

Have you ever been hospitalized for mental health? If so, when, where, and for what? *

Please describe your symptoms and the reason you are reaching out to The Kulkarni Group. *

How long have you been struggling with these symptoms? *

If the patient is a minor, who else lives in the home with the patient? *

If the patient is a minor, and the parents are divorced, which parent/guardian has authority to make decisions in medical care? *

Scheduling Info

Were you referred to a specific provider in the practice? If so, who? *

Some of our providers see patients in office and telehealth, some do not. Do you prefer to see the provider in person or via telehealth? *

Please list the best days and times for our Intake Coordinator to contact you via telephone. *

Payment Info

What will be the primary payment method? *

Blue Cross Blue Shield

Other

What is your Member ID? *

What is your Group Number? *

Policy Holder Name, Date of Birth and relationship to the patient? *

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