Well-Minded Healthcare Inquiry Form

If you are experiencing a psychiatric or medical emergency, please call 911 or present to your nearest Emergency Room.

Complete this form to get connected to a provider at Well-Minded Healthcare

Your First and Last Name

Your email address

Your Phone Number:

I am completing this form for

Myself Someone else

(my child)

Other

Please note we will not reach out and initiate services for anyone over 18 if the person completing this form is not the legal guardian. Please encourage the individual seeking services to complete the inquiry form themselves.

Prospective client first and last name

Your Date of Birth:

Prospective client date of birth

Are parents married?

Yes, married

No, separated, shared custody

both parents must agree to treatment

No, divorced, shared custody

both parents must agree to treatment

Other

please explain

Other parent first and last name

Other parent email address

I am looking for:

Medication Management only

Therapy only

Medication and therapy

Your insurance plan name

Are you the primary insured?

Yes No

Primary Insured/Policy Holder First and Last Name:

Insurance Member ID # for prospective client:

Prescriber Preference

Benjamin Brondsky, PMHNP

Prescriber serving clients 16-65

Rebecca Blair, CPNP, PMHNP

Prescriber serving clients 4-50

Kasia Ross, PMHNP

Prescriber serving clients 16+ offering medication management and therapy

Maria Romanoff Rand, PMHNP, DNP

Prescriber serving clients 18+

No Prescriber preference/first available

Therapist Preference

Michelle Birdwell, LMHC

Therapist serving clients 18+

Your therapist's name

Current and Past Psychiatric Medications

Please include all medications and supplements you are taking including directions for use and doses. Please also add previous trials of psychiatric medications.

Please tell us about your reason for seeking treatment.

If you have previously been diagnosed with ADHD and are interested in starting, restarting, or continuing stimulant medication, we will need documentation confirming your prior diagnosis. Acceptable documentation may include a neuropsychological evaluation report or a diagnosis documented by a pediatrician or primary care provider in your medical record.

If you do not currently have documentation, or if a re-evaluation is needed, we can support you in gathering the appropriate information to help guide an accurate diagnosis.

Have you ever been hospitalization for a psychiatric reason?

Yes

Has the prospective client ever been hospitalization for a psychiatric reason?

Yes

Please provide date(s) and reason(s) for hospitalization(s)

Do you have concerns regarding substance use?

Yes

Unsure

Please describe current substance(s) use and pattern of use

Please describe potential concerns around substance use

Do you have concerns regarding disordered eating?

No concerns

Yes

Yes in the past (more than 5 years)

Unsure

Please describe your concerns around disordered eating

Please provide information regarding past concerns

Please explain current potential concerns regarding disordered eating

Who referred you to our practice?

If you are experiencing a mental health or medical emergency do not use this form, instead call 911, go to your nearest emergency room or call/text 988.

Your information will be encrypted.