Solid Ground Psychiatry PLC

Your info

First name

Last name

Phone

Name you go by

Reason for care

Thank you for reaching out about becoming a potential patient of the practice! In order for me to assess whether I can help you appropriately, please complete the following prescreen questionnaire. Please note that until I have accepted you as a patient, you have not formally been accepted into the practice nor have we established a doctor-patient relationship. If this request is an urgent matter, please call 911 or go to your local emergency room. If this request is not an emergency or urgent matter, please click "yes" below indicate that you wish to proceed:

Yes

Are you seeking a Psychiatric Assessment and follow-up Psychiatric follow up care if needed? (Note: If you answer no, you may not wish to proceed with this form as Dr. Lasek does not provide weekly psychotherapy at this time.)

Yes No

Please check all of the following that are applicable to you:

In therapy now Taking psychiatric medication now Have been hospitalized for mental health reasons Having suicidal thoughts or attempted suicide in the past Currently seeing a psychiatric provider

Please tell me about the person for whom treatment is being requested:

Limited to 600 characters

What are the main issues leading you to seek treatment at this time? Please provide as much detail as you are comfortable providing. This will help ensure that we are a good match.

Limited to 600 characters

If you are taking any psychiatric medications please list them below:

Limited to 600 characters

Are you seeing a therapist currently? If so, who are you seeing and how often are you seeing them?

Limited to 600 characters

I ask that all new patients have an established PCP, have seen their PCP in last 12 months and that records from your PCP are forwarded to the office. Who is your Primary Care Provider (PCP)? When is the last time you had an appointment with your PCP?

Limited to 600 characters

Administrative

Do you have any scheduling limitations? Are there any times that would NOT work for scheduling appointments?

Limited to 600 characters

How were you referred?

Billing & Payment

What will be the primary payment method(s)? If you have secondary insurance please also include that. (Please note the practice is only accepting new patients with the insurances listed below.)

Private pay/out of pocket Blue Cross Blue Shield Cigna/ Evernorth Harvard Pilgrim Medicare MVP

If you plan on using insurance, please upload a photo of your insurance card below. For private pay, please select "N/A"

Have uploaded an insurance card below N/A

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Thank you so much for completing the prescreen questionnaire! Please note that it can take up to one week to respond to your request after receiving the pre-screening questionnaire. If I am able to accept you into the practice, you will receive a message with intake forms including a patient questionnaire and practice policies. If I am unable to accept you, I will send you a message with other potential referral resources.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.