RGMH Consultation Interest Form

Rockfish Gap Mental Health PLLC

Benjamin Pumphrey MD

Please complete this form to initiate a conversation with Dr. Pumphrey about your interest in a psychiatric consultation. He will contact you within 2 business days to discuss your interest further.

This form is secure and will be sent to Dr. Pumphrey in an encrypted form.

Please note that assessments for ADHD may involve conversation with family members, formal neuropsychological testing, and/or review of past school records

This form must be completed only by the person requesting a consultation. I certify that I am completing this form for myself, am requesting a consultation appointment only for myself, and that I am over 18 years old.

No Yes

Dr. Pumphrey provides care to people 18 years old and up. Please consider a different psychiatric clinic for your needs.

I understand that I must not complete this form if I am currently experiencing an emergency or have urgent needs. I certify that I am not currently experiencing a psychiatric emergency or have urgent psychiatric needs. (Note: If you are having an emergency, call 911 or go to the closest emergency room immediately)

No Yes

If you are having an urgent need or an emergency, please do not complete this form. Please contact 911 or go to the closest emergency room.

I understand that Rockfish Gap Mental Health PLLC is a Telepsychiatry practice. I feel meeting with Dr. Pumphrey via videoconferencing is appropriate for me and my needs.

No Yes

Dr. Pumphrey only provides care via videoconferencing (telepsychiatry). Please consider a different psychiatric clinic for your needs.

I understand that I will need to be located within Virginia for every telemedicine appointment.

No Yes

State medical licensing and treatment laws require consultees and patients to be in the state where the physician's medical license is held. Please consider a different psychiatric clinic for your needs.

First name

Last name

Phone number

PCP Name

Please briefly describe your interest in a consultation with Dr. Pumphrey

How did you hear about Dr. Pumphrey or Rockfish Gap Mental Health?

Please indicate the insurance you plan to use

Anthem BCBS

Commercial, not Medicaid

Aetna

Commercial, not Medicaid

I plan not to use insurance and will pay your out-of-pocket rates

Dr. Pumphrey can provide statements that you might be able to provide your insurer, for some reimbursement (if you have out-of-network benefits). The fee for the initial consultation is $300 (up to 90-minutes). Follow-up visits may range from $105 to $210 depending on needs.

Your information will be encrypted.