Clinical Info
How were you referred to me? *
Are you intending to continue or taper a current controlled medication prescription? If so, please say more here. *
What state do you currently live in? For example, Virginia, Tennessee, other... *
How would you prefer to be addressed? Please include pronoun, title and any other preferences. *
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Scheduling Info
Are there any times that would NOT work for scheduling an appointment? *
Do you have any other scheduling limitations? *
This is a tele-health clinic, and we only meet by video, which requires a private place to meet like a room or a parked car, as well as a smart phone or computer and a high speed internet connection. Are you able to connect that way? *
When are you intending to schedule your first visit? *
$600 is due in advance to reserve your first formal 90 minute consultation for the purpose of taking your history, formulating an assessment of your conditions and a plan for your recovery, as well as answering your questions and obtaining your informed consent for any therapies we plan on.
If you require medication management and you require a 30 or 90 day supply, I bill a 1 or 3 month deposit in advance, which covers up to half an hour of consultation time in (each of) the final 1 (or 3) month(s) of membership. Would you prefer a 1 or 3 month supply of medication? *
Do you have any questions about how to budget for these options?
After you complete this form, I will message you here on Luminello.com on the next week day when I am in the office with next steps to schedule a free 15 minute informal consultation. If you would like to skip this step and schedule a formal 90 minute consultation, answer "yes" and copy and paste this link into your browser to invoice yourself in advance:
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