Appointment Request Form

At this time, we are currently not accepting Child and Adolescent Intake Requests for Lyra.

While our practice is accepting new patients, not all requests may result in an appointment, as our priority is to ensure the best fit for both patient and provider. Our providers work part-time, balancing teaching, research, and university-based patient care. This form is designed to help us connect prospective patients with a psychiatrist whose specialty, availability, and financial policies align with their needs. In some cases, we may not offer an appointment if we feel we may not be able to provide the appropriate level of care required (e.g. limitations due to telehealth process). In those situations, we believe it’s in the best interest of the patient to find a provider who can better meet their specific needs and circumstances.

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. This form is HIPAA compliant to ensure the protection of your privacy.

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)

Blue Cross Blue Shield (Note: We do not accept Premera)

First Choice Health

Lyra

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.