Initial Screening

Spectra Integrative Psychiatry

Please correct the errors described below.

The purpose of this form is to assist with matching you to the most appropriate services. Submission of this form in no way guarantees acceptance as a patient or creates any form of provider-patient relationship; if Dr. Moore is unable to schedule you at this time, a staff member will contact you to offer any potential appointments with other providers that work closely with Dr. Moore.

Adults and adolescents ages 13 to 17 should complete the below information themselves, while children ages 6 to 12 should be assisted by a parent or guardian.

Note that the more information you can provide, the better able we can assist you; if we need more information, you may receive a follow-up call for clarification. We intend to contact you to discuss options within 5 business days following your submission here.

Please put "n/a" if you are not currently working.

Insurance Information

Dr. Moore is not currently in-network with Medicare, Medicaid, Apple Health, United Healthcare, Cigna, Molina, Beacon, or Optum. If you wish to discuss Cash Pay / Out-of-Network rates for Dr. Moore, please call our office at 425-968-5948.
Please include any alpha prefixes, as appropriate. If you do not plan to utilize any insurance coverage, please type "n/a."
If you do not plan to utilize any insurance coverage, please type "n/a."

About Your Request

Please be as specific as possible.
If none, please note "n/a."
These are most commonly ordered by either a psychiatric provider or a primary care provider. If none, please note "n/a."
If none, please note "n/a."
If none, please note "n/a."
If yes, please note approximate dates, durations, and whether the stay was voluntary or involuntary.
If so, was/is this drugs (including cannabis), alcohol, or food? Please include approximate dates if in the past.
If yes, please note approximate dates (ex: "The last time I felt that way was _____ weeks ago / months ago / years ago" OR "I felt that way in middle school / college / age 22-25," etc.))
If yes, please note frequency, intensity, etc.
If yes, is this current or in the past? Is this a divorce, restraining order, lawsuit, criminal charges, etc.?
If yes, was this in the past, present, etc.? (Examples might include throwing objects, punching walls, road rage, assault, etc.)

Referral Information

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