Yerardi Psychiatric Services LLC

Yerardi Psychiatric Services LLC Send Message

Who would be receiving care?

Me

Someone else

Your info

First name

Last name

Email

Phone

Name you go by

Date of birth

Legal gender

Male Female

Gender identity

If different from legal gender

Address

Full address including City, State and Zip Code

Phone number

Email address

Reason for care

What is the reason for seeking care?

Depression Bipolar disorder or mood lability Anxiety OCD Trauma Attention difficulties Behavior problems Other

What kind of care is being sought?

Medication Consultation Second opinion Other Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Engaged in a partial hospitalization program (PHP) or intensive outpatient program (IOP) for mental health reasonsnow or recently Completed a PHP and/or IOP for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past Struggling with active substance use disorder (note: we do not treat SUD as the primary problem) History of substance use disorder (in remission) Struggling with active eating disorder (note: we do not treat eating disorders as the primary problem) History of eating disorder (in remission) Other None of these apply

Billing & Payment

Payment method

How do you plan to pay?

Insurance carrier

N/A if self-pay

Insurance ID #

N/A if self-pay

Administrative

Therapist's name and phone number

PCP's name and phone number

By whom you were referred

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.