Screening and Referral Form

Screening and Referral Form

New patient initial screening form Form Preview
Screening and Referral Form
  • Screening and Referral Form

    Island Psychiatry, PC.
  •  -  - Pick a Date
  • Intro Script:

    We would like to see if we can help you.  Do you have about 10 minutes for a few personal questions about your [or patient's name] situation?  This would help us determine if we are able to support you here and help us match you with a provider that would have the most expertise in supporting you [or patient's name]


  •  -
  •  -


    Do you accept Insurance?
    While we do not accept insurance as payment, our practice will submit insurance benefits on your behalf to assist you in collecting reimbursement for any covered treatment at our office.

    What are your fees?
    We have a set fee of [$$$] for [PROVIDER'S] services, unless you have significant financial hardship. Are you ok with those fees?
    Yes= Proceed as usual to set up an appointment
    No= If you have a hardship, we have a financial hardship application that will help us assess your situation in the hopes that we accommodate your needs. Would you like to complete the financial hardship application? 
    Yes= Email Application- paste in this link Click to Complete the Financial Hardship Application
    No= May we assist you with a referral?


  • Should be Empty: