New Patient Request

For emergencies, dial 9-1-1

This form is for new patient requests only. For emergencies, dial 9-1-1.

Basic information

Patient name

Age (patients must be 18 or older)

Date of birth

Phone number

Email address

Clinical information

What type of care are you seeking?

Medication Therapy Both

Tell me your reasons for seeking care

Scheduling information

Do you have any scheduling limitations? (Any times during the week that would NOT work for scheduling an appointment)

If I have availability and provide the services you are requesting, I will contact you directly to schedule.

Payment information

Please note that Katherine Day Mitchell, MD, is not a participating provider in any insurance plans. Patients are responsible for payment in full at the time of service. If your insurance plan allows, you may seek reimbursement directly from your insurance company.

Select the following checkbox to confirm that you understand and acknowledge this information.

I understand

Your information will be encrypted.

New Patient Request

For emergencies, dial 9-1-1

Basic information

Clinical information

Scheduling information

Payment information

For emergencies, dial 9-1-1

Katherine Day Mitchell, MD

ABPN board-certified psychiatrist