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

Full Address (Street, City ,Zip code) *

Reason for appointment: *

Are you on any treatment? If yes please explain *

Dr Sajid Faizi only treats patients ages 13-65 in his outpatient clinic. Please specify your age? *

Emergency Contact *

Dr. Faizi does not treat substance use disorder at this clinic. Please acknowledge that you are not seeking substance use treatment. *

Payment Info

What will be the primary payment method: Credit card, Health Savings Account?
*For payment inquires please call 435-695-0439 *

Sajid Faizi, MD is only accepting cash patients at the Sandy location. I understand I am responsible for payment in full before my appointment. If requested, I will be provided a statement so I may try to get some reimbursement from my insurance company, if I am eligible. .Please confirm you understand the fees for Dr Faizi's practice and agree to payments in full before your appointments. Here is the fee schedule :
Initial Assessment $300
Follow-up $150 *

Sajid Faizi, MD

Current Availability

Location

Payment Methods

Client Focus

Treatment Focus

Clinical Info

Payment Info

Sajid Faizi, MD

Current Availability

Location

Payment Methods

Client Focus

Treatment Focus

Clinical Info

Payment Info

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