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 *

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 medications are you taking? *

Do you have any medical conditions I should know about, including physical limitations requiring assistance devices? *

Did you find me through SB Independent, Psychology Today, Montecito Journal, Daily Nexus? If not, please state how you were referred, and please lmk the name if it was one of your treaters so I can thank them. Thank you! *

Are you a current or fomer Lifestance patient? *

Scheduling Info

Attestation of terms and conditions:

PLEASE NOTE: IF YOU HAVE AN URGENT ISSUE OR AN EMERGENCY PLEASE CALL 911 IMMEDIATELY OR GO TO THE NEAREST EMERGENCY ROOM.

PLEASE NOTE: APPOINTMENTS IN THIS PRACTICE NEED TO BE MADE 1 WEEK IN ADVANCE. IF YOUR ISSUE IS MORE URGENT THAN THAT PLEASE SEE ABOVE OR SEEK ALTERNATIVE CARE. THANK YOU!

This is a telepsychiatry practice and may not be appropriate for every patient. This practice focuses on ADHD as well as relationship oriented issues for individual patients. Please read the following carefully and sign below to indicate you've read the items below and understand this practice is not appropriate for you if:

1. You want to hurt yourself or someone else or you are not taking care of yourself. If you have been suicidal or homicidal recently please call 911 or go to the nearest emergency room.

2. You have been in an inpatient or partial program within the last year.

3. You are looking for in office treatment. This practice is tele-psychiatry only. Some conditions may not be appropriate for this practice.

4. You are seeking to take benzodiazepines such as lorazepam (ativan), clonazepam (klonopin), or alprazolam (xanax), or have had a prescription for these recently.

5. You have a substance abuse issue with alcohol, cocaine, pcp, lsd, opioids, are on suboxone or methadone or are in recovery. Please see a specialist for wraparound services.

6. You are looking for forensic psychiatry services as a part of a legal case. This includes, but is not limited to, evaluations for a legal case, serving as an expert witness, or testimony as a part of a legal case. Please seek the care of a forensic psychiatrist.

7. You are looking for disability, off work, employment or travel screening.

8. You are only looking for an ESA letter for your pet. Online services specializing in this area are often preferred by patients

9. You have an eating disorder. Please see a specialist for wraparound services

10. You are not able to fill out paperwork yourself or you are not able to do appointments by yourself. In these cases please see a provider in person, instead of via telepsychiatry.

PLEASE NOTE:

A. Cancellations within 3 business days of your scheduled appointment, as well as no shows will be charged at the full rate.

B. The first meeting is a consultation to establish whether there is a good fit for this practice. If mutually agreed a follow up will be scheduled.

C. You affirm you are not driving, or in need of concentrating elsewhere while in session.

D. You understand the practice recommends during our sessions I secure a private space, with no recording devices present, and no unwanted people present or able to hear our conversation. I understand if I do not follow these recommendations I do so at my own risk of my privacy being compromised.

PLEASE TYPE YOUR NAME BELOW TO INDICATE YOU READ AND UNDERSTAND THE ABOVE. YOU WILL NOT BE SCHEDULED WITHOUT YOUR AFFIRMATION BELOW.

*

If there are technical difficulties during audio/visual sessions it is hellpful to know which carriers are affected. Which internet carrier do you use for phone and computer? *

Payment Info

1. Dr. Bolton does not accept any insurance or single case agreements. There is sometimes confusion because Dr. Bolton may be listed on several insurance panels due to past and current practice or hospital affiliations. However for this private practice, “Michael Bolton, M.D., A Professional Corporation” is a separate business entity and is considered “out of network”. We do not want to be limited in how we treat our patients, and we want to make sure the insurance company does not interfere with making you our priority. Payment is due at the time of our meeting, but you may submit the receipt to your insurance company. Depending on the insurance provider, they will sometimes reimburse you, but this is not guaranteed. You are responsible for redacting any sensitive information on the receipt or superbill you may send to any third party. Your receipt is your superbill.

Rates:
Initial consult: $300
Standard follow up: $200
Extended follow up: $300

PLEASE TYPE YOUR NAME BELOW TO INDICATE YOU READ AND UNDERSTAND THE ABOVE. YOU WILL NOT BE SCHEDULED WITHOUT YOUR AFFIRMATION BELOW. *

Please indicate what type of insurance you have. Although we are not credentialed with any insurance plans we do not take patients who have certain types of insurance, because some insurance companies make the superbill process difficult.

PLEASE INDICATE THE TYPE OF INSURANCE YOU HAVE (EX, CIGNA, MED-CAL, MEDI-CARE) BELOW, AS WELL AS YOUR FULL NAME TO INDICATE YOU READ AND UNDERSTAND THE ABOVE. YOU WILL NOT BE SCHEDULED WITHOUT YOUR AFFIRMATION BELOW. THANK YOU. *

Michael Bolton, MD

Current Availability

Fee Range

Insurance Accepted

Client Focus

Clinical Info

Scheduling Info

Payment Info

Michael Bolton, MD

Current Availability

Fee Range

Insurance Accepted

Client Focus

Clinical Info

Scheduling Info

Payment Info

Just checking...