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? *

Check all of the following that are applicable: *

In therapy now

On psychiatric medication now

In the hospital now or recently

In therapy in the past

Taken psychiatric medication in the past

Attempted suicide in the past

Hospitalized for psychiatric reasons in the past

Known neurologic or genetic disorder

None of the above

If the patient is not their own legal guardian, please list all of the patient's legal guardians and whether each guardian is aware that psychiatric care is being sought and consenting to that care? *

Please tell me about the main symptoms that have been causing problems and how they developed or changed over time. *

If psychiatric medication has been tried in the past, which medicines, at what doses and for how long? Were they helpful? Were there any side effects? *

Have there been any suicide attempts or self-harm? If so, what were the triggers, when did they occur, and what helps prevent these instances? Are these still ongoing difficulties? *

If there were hospitalization(s) for psychiatric reasons in the past, please tell me a little more about the experience(s). *

Do any psychiatric conditions run in biologic relatives? If so, what medications or treatments, if any, were helpful? Were there any that worked badly? *

Is there any history of trauma? What about major life changes, losses, or disappointments? *

Are there any medical problems? Please also include any history of seizures, head injuries and cardiac abnormalities. *

If born biologically female, is the patient pregnant, planning to become pregnant, or nursing? *

Are there allergies to any medications? *

What are the current psychiatric medications? Please include names, doses (in mg), and frequency of administration. *

What are the non-psychiatric medications? Please include over-the-counter medications, herbal supplements, naturalistic remedies, vitamins, and minerals. *

What substance use is present in the patient? Please list quantities and frequency of use for marijuana, tobacco, alcohol, and other illicit substances. *

I know we have asked for a lot of personal information already, but please tell me what else we need to know in order to take good care of you and keep you comfortable during our sessions. If you have not included it in the information above, please let me know how the patient prefers to be addressed and any preferred pronouns (he/him, she/her, they/them, etc.). *

Scheduling Info

Are there any times that would NOT work for scheduling an appointment? *

Do you have any other scheduling limitations? *

Payment Info

Stephanie Stavish has a business agreement with Headway, which provides Virginia patients with a new payment option if they wish to use their health insurance benefits through Aetna, Carefirst, Cigna, Oscar Health, Oxford, or United Healthcare. If you are a Virginia patient hoping to use your health insurance benefits through Aetna, Carefirst, Cigna, Oscar Health, Oxford, or United Healthcare, please let us know below so that we can have Headway reach out to you to make arrangements. *

Stephanie Stavish does not participate in insurance plans, except through Headway, and does not take Medicare or Medicaid. I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made (i.e. if I create a Headway account prior to the appointment and am using Headway for the aforementioned commercial insurances). I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible. *

Although Sunshine Psychiatry offers services through telepsychiatry, our providers are only allowed to practice in states where they are licensed. I am aware that patients will need to physically be in DC or Virginia at the time of the appointment to receive services through Stephanie Stavish. *

Stephanie Stavish, PMHNP-BC

Current Availability

Clinical Info

Scheduling Info

Payment Info

Stephanie Stavish, PMHNP-BC

Current Availability

Clinical Info

Scheduling Info

Payment Info

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