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Contact info

How did you hear about Elevate Medical?

We will only use this for scheduling and clinical communication



Eligibility

State you will be located in during telehealth visits
Insurance plan

Clinical reason

A brief selection helps us match you with the right services.

Primary goal of treatment
Medication management
Therapy
Both
Evaluation only
Are you specifically interested in Spravato treatment?
Yes
No
Unsure
Elevate Medical emphasizes careful evaluation, safety, and collaborative treatment planning. Does this approach match what you are seeking?
Yes
I'd like to learn more
Unsure
What concerns would you like evaluated? (Select all that apply)

Most care is provided via telehealth.

Spravato visits are in-person (Midtown Manhattan).


Care Background

Have you previously worked with a psychiatrist or psychiatric provider?
Yes
No
Have you had a psychiatric hospitalization in the past 2 years?
Yes
No
History of substance or alcohol misuse, dependence, or treatment
No
Past history
Current concern
Prefer to discuss
Are you currently experiencing thoughts of harming yourself or suicidal thoughts?
No
Passive thoughts only
Prefer to discuss privately
Active thoughts

If you are experiencing an immediate mental health emergency, please call 988 or go to the nearest emergency room. This form is not monitored continuously.


Privacy note:  Information submitted here is kept confidential and used only for scheduling and eligibility screening. Please avoid including detailed medical information in this form.


Requests are typically reviewed within two business days.

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