Luminello

This form helps prospective patients/clients and clinicians connect more efficiently and explore whether the requested relationship will be a good fit. As clinician skill sets, availability, and financial policies vary, this form helps ensure you find the right clinician for your needs.

If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911 or go to your closest emergency room.

This request is not an emergency or urgent matter. I wish to proceed

Clinical Info

Please tell us about the person for whom treatment is being requested

Patient/client first name *

Patient/client last name *

Patient/client gender *

Date of birth *

My relationship to the patient/client *

My phone number *

How were you referred to me? *

What kind of care is being sought (i.e. psychotherapy, psychological testing, not sure)? *

Scheduling Info

Would you like to be contacted by phone or email? *

If by phone, is it okay if I leave a voicemail? *

If by email, what is your email?
Please note that email is not a HIPAA compliant secure platform. The privacy of your medical information is very important to me. We will coordinate a time to talk, not discuss clinical information. *

Payment Info

Diana Ro, PsyD does not participate in insurance plans. I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible. *

Yes

Diana Ro, PsyD

Current Availability

Location

Clinical Info

Scheduling Info

Payment Info

Diana Ro, PsyD

Current Availability

Location

Clinical Info

Scheduling Info

Payment Info

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