Treatment Request Patient/client name * First Name Last Name Patient/client pronouns * Date of birth * (e.g. mm/dd/yyyy) Phone * (###) ### #### Email * My relationship to patient/client * How were you referred to me? * Check all of the following that are applicable: * In therapy now On phychiatric medication now In the hospital now or recently In therapy in the past Taken psychiatric medication in the past Attempted suicide in the past Hospitalized for psychiatric reasons in the past Known neurologic or genetic disorder None of the above What kind of care is being sought? * Medication Psychotherapy Both Not sure At this time, ADHD evaluations and/or treatment for moderate to severe problems with substance use are not in my scope of practice. Is this consistent with what you need in treatment currently? * * Yes No Please list all current medications or supplements you are taking for your mental health: * Please indicate any of the main issues for which you are seeking treatment (e.g. anxiety, depression, trauma, grief, moodiness, autism spectrum, anger, eating/body image, relationships, existential fear, other...): * Please list any prior mental health diagnoses: * I currently only have openings for new patient evaluations in person on Wednesday through Friday, does that work for you? * Yes No Megan McNamee, MD does not participate in insurance plans. I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible. * Yes No Thank you for completing the treatment inquiry form. Dr. McNamee generally responds to treatment inquiry requests within one week. She will contact you by the phone number or e-mail you provided.