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Tye Johnson-Mason, DNP, APN-BC
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Consultation Request
Relationship to Client
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Check all of the following that are applicable:
In therapy now
In the hospital now or recently
Taken psychiatric medication in the past
Hospitalized for psychiatric reasons in the past
On psychiatric medication now
In therapy in the past
Attempted suicide in the past
Known neurologic or genetic disorder
None of the above
How were you referred to office?
What kind of care is being sought?
Medication
Psychotherapy
Both
Unsure
Other: Please Specify
What is your reason for seeking care? (Please be as specific as possible, including functional concerns, symptoms, duration, etc.)
Do you or does anyone close to you have concerns about your current substance use? (If yes, please provide details.)
Do you or does anyone close to you have concerns about you having current violence or violent actions? (If yes, please provide details.
Are there any current or ongoing legal concerns, including court proceedings, probation, etc.? (If yes, please provide details.
Please verify that you are informed that we only can see patients for appointment when they are located within the State of New Jersey.
What will be the primary payment method?
Commercial Insurance
Medicare
Self Pay
If your insurance plan is accepted by the clinician, what is the policy ID number? For private pay, enter 'n/a'.
Do you consent to receive text messages and for us to leave voicemails?
Yes
No
You will receive an email from the office requesting registration if you are in network with insurance. This registration process is mandatory to utilize insurance benefits. At this time, we are unable to accept any Medicaid plans. Enter 'I agree' or 'N/A' if you plan on private pay.Â
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