Thank you for your interest in our psychiatric care. We do our best to match patients with their chosen providers, though it is not always possible.

The following psychiatric providers are taking new patients:

• Daphne Chin MD, Psychiatrist

• Robert Jones MD, Psychiatrist

• Kalia Rothlind, Psychiatric Nurse Practitioner

• Cris Bissonnette, Psychiatric Nurse Practitioner

Please answer the following questions so we may more efficiently provide the care you need:

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Full Name *

First

Last

Will you be the patient? *

• Yes
• No

This form is to be completed by the person seeking services or a legal guardian of a minor.

Email *

Contact by email does not constitute a working therapeutic relationship or doctor-patient relationship.

Phone *

Date of Birth *

Gender

PronounsSelect oneShe / HerHe / HimThey / ThemOther

What symptoms or concerns?

• Anxiety
• Difficulty Sleeping
• Suicidal Thoughts
• Depression
• Hallucinations
• ADHD Assessment
• ADHD Treatment
• Mood Swings
• Irritability
• Other

Do you…?

• Want to learn about possible medications for your symptoms: purpose, how they work, side effects etc?
• Already have a medication regimen that you want to continue?
• Currently have medications but are unsure if you want to continue?
• Take medications but are wondering if something else might be better (more effective/fewer side effects etc.)

Are you currently experiencing a mental health crisis?

• Yes
• No

If yes, what's the nature of your crisis?

Have you ever been hospitalized for your mental health?

• Yes
• No

If yes, what hospital?

Date of Hospitalization

Do you have a current provider for psychiatric care?

• Yes
• No

interested Will been

If yes, why are you interested in switching providers?

Do you currently have a psychotherapist?

• Yes
• No

Please list all of your home medications ( psychiatric and non-psychiatric), including dose and frequency:

Payment *Select onePrivate Pay/Out-of-PocketAetnaAlameda AllianceAnthem / Anthem Blue CrossBlue CrossBlue Cross/Blue Shield FEPBlue Shield of CABlue Shield with MagellanCignaHealthNetKaiserMagellanManaged Health NetworkMedicareMeritainUC SHIP

If your insurance is not listed we do not accept it at this time. Contact us with any questions.

Prefer Therapy In Person or Virtual/Telehealth *Select oneIn Person OnlyTelehealth OnlyBoth are okay

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