Initial Screening

Spectra Integrative Psychiatry

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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.

Insurance Information

You must contact your insurance company to confirm that Lee Moore, ARNP, is in-network. While he is in-network with most plans administered by the above companies, there are unique plans that may not include Dr. Moore within their network.

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 so, please note approximate dates, durations, and whether voluntary or involuntary.
If so, was or is this drugs, alcohol, or food? Please include approximate dates if in the past.
If so, is this current and/or in the past (and approximately how long ago)? Has this ever lead to any self-inflicted harm?
If so, is this current or in the past? Is this a divorce, restraining order, lawsuit, etc.?
If so, does or did this include throwing objects, punching walls, road rage, or something else?

Referral Information

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