Appointment Request Form

Please note that not all requests will lead to appointments. Our providers are part-time and continue to teach, do research, and treat patients at their university jobs as well. This form helps prospective patients and providers connect more efficiently and explore whether the requested relationship will be a good fit. As provider specialty, availability, and financial policies vary, this form helps ensure you find the right psychiatrist 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.

Please start by reading our general information form describing our standard adult, child, and adolescent psychiatric evaluations, including fees.

If you agree to the terms, please complete the following appointment request form.

Clinical Information

Have you submitted a request for another patient in the past? *

What kind of services are you seeking? *

Relationship to the patient *

Contact First Name *

Contact Last Name *

Contact E-mail *

Phone *

Patient's First Name *

Patient's Last Name *

Sex *

Patient's date of birth *

If the patient is 13 years of age or older, please provide their email address: *

Please provide your state of residence *

Select all of the following that are applicable *

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

If "other" please specify main issues:

Feel free to elaborate on the reasons for consultation

List current medication *

Please list any psychiatric medications taken in the last year (If applicable):

Are you experiencing suicidal ideation (having thoughts of wanting to end your life)? *

Yes

Have you ever attempted to end your own life? If "yes," when? *

Is the patient experiencing suicidal ideation (having thoughts of wanting to end their own life)?

Yes

Not sure

Has the patient ever attempted to end their own life? If "yes", when? *

Payment Information

What will be the primary payment method?

Private Pay (Out-of-Network)

Regence Blue Cross (Not Premera)

First Choice

Lyra

If other

How Did You Hear About Us? *

Terms and Conditions *

I have reviewed and agree to the terms and conditions in the adult/pediatric evaluation form listed above.

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Montenegro & Associates Behavioral Health, PLLC providers and/or office staff communicating with me via email or text message.