Empowered Psychiatry PLLC | SimplePractice

Empowered Psychiatry PLLC Send Message

Who would be receiving care?

Someone else

Your info

First name

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Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

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Reason for care

What is the reason for seeking care?

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Is there anything the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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Administrative

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Billing & Payment

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Out of pocket Insurance

Insurance details

Please provide this and upload a picture of the card so we can determine if we are associated with this plan!

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Insurance card upload

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Client Preferences

Preferred location (intakes are 90 minutes in person)

Newton Northampton Marshfield

Preferred Clinician

We try to accommodate requests depending on location and availability

Ashley Starr (Northampton) Eric-Paul Olsson (Newton) Mark Monfasani (Newton) Susan (Marshfield, Newton) No Preference, soonest available

Have you been hospitalized in the last 90 days for psychiatric purposes?

Yes No

If yes, please explain circumstances - we will need discharge summary/paperwork prior to meeting!

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.