New Patient Inquiry - LSBH Therapy

Comments

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Lifespan is currently welcoming new patients ages 6+ for medication management, and 18+ for therapy.

This form is for New Patient appointments only. For current patients, please visit https://lsbhtherapy.com/contact-us/ for locations and contact information.

After you submit this form, a member of our team will contact you with information on how to complete the registration in our Patient Portal. Once the necessary documents are complete, we will schedule the first available appointment with one of our providers. Thank you for reaching out to us and we welcome you to our practice.

Patient's Name*

First Last

Email*

Preferred Phone Number*

(###) ###-####

Address*

Street Address City State ZIP Code

I am inquiring about services for*

Date of Birth*

Name of Insurance Carrier

If your insurance is not listed in our drop down menu, then we do not participate with your carrier and you will need to pay our self pay rates listed in our Fees & Insurance menu.

Please upload a copy of your driver's license and insurance card (front and back)*

You can upload multiple files at the same time.

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, heic, Max. file size: 48 MB.

Services Requested*

You may select more than one answer.

Therapy
Medication Management
Amy Schwartzbaum, MS, PA-C, CAQ-Psyc - Ketamine Assisted Psychotherapy Medication Evaluation (upload referral from your provider in order to be seen)
Employee of WMATA/METRO
Other

Please upload a referral form for Ketamine Assisted Psychotherapy Medication Evaluation from your provider

Accepted file types: jpg, jpeg, gif, png, pdf, heic, Max. file size: 24 MB.

How did you hear about us?*

Comment or Message

Limit to 100 characters

Terms of Use*

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Lifespan Behavioral Health Services harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Yes, I want to submit this form.

File

Accepted file types: jpg, jpeg, gif, png, pdf, heic, Max. file size: 24 MB.

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