New Patient Inquiry- Capital Mental Health
For Adults
Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
How do you hear about us?
*
Friend / Family
Physician Referral
Google
Social Media (e.g., Facebook, Instagram)
Online Reviews (e.g., Yelp, Healthgrades)
Other
Referring Physician:
*
Patient's Occupation
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Are you married?
Yes
No
Spouse's Name
First Name
Last Name
Spouse's Occupation
Spouses's Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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Next
What is your primary concern or reason for seeking care?
*
Are you seeking therapy, medication management, or both?
*
Do you have preferred days and times to see your provider?
Do you have a preferred physician or provider?
Barbara Byers, MD, MPH
Robyn L. Wechsler, MD
Viviana Bauman, PhD
Michael Bogrov, MD
Elspeth Dwyer, MSW, MS, PMHNP-BC
Elissa Hauptman, DNP PHMHNP-BC
Ursula Kahric, LCSW-C
Mariam Kashani, DNP PMHNP-BC
Edie Mead, LCSW-C
Aleeza Michael-Tabrizi, LCSW-C
Karen Riibner, LCSW-C
Alexis Rubin, LCSW-C
Neil Rustgi, MD
Emee Ta, MD
Damira Vulas, MD
Submit
Should be Empty: