Consultation Request

CONSULTATION REQUEST FORM

Notice: If you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent matter, please call 911 or report directly to your nearest emergency room.
This request is not an emergency:
*Requests for an initial consultation appointment will be reviewed and responded to within 2 business days.
Relation To Patient:
Is there a custody agreement in place?
If there is joint custody in place, I understand that prior to the initial consultation I will need to submit a consent form signed by the parent that shares custody. This consent form will be emailed to me prior to the initial consultation. If the other parent shares custody is not able or unwilling to sign prior to the initial consultation, I will need to provide paperwork stating that I have 100% medical decision making authority:

- PATIENT CONTACT INFORMATION
- Patient Name:
  
  First NameMiddle NameLast Name
- Date of Birth:
  
  MonthDayYear
- Sex Assigned at Birth:
- Preferred Pronouns:
- Patient Email Address
- Patient Home Address:
- Patient Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Referral Source:

- PARENT CONTACT INFORMATION
- Parent Name:
  
  First NameMiddle NameLast Name
- Parent Date of Birth:
  
  MonthDayYear
- Sex Assigned at Birth:
- Preferred Pronouns:
- Parent Email Address
- Parent Home Address:
- Parent Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.

ACKNOWLEDGEMENTS
I understand that Walls Down Wellness cannot accommodate patients with a history of residential treatment, history of rehab programs for substance use, active drug/alcohol use disorders, psychosis, history of eating disorders, and/or suicide attempt(s).
I understand that Dr. Rao does not prescribe benzodiazepines long term (e.g., Xanax, Ativan, Klonopin) but is willing to work with patients to determine safe alternatives. I also understand that Dr. Rao routinely checks the statewide prescription monitoring program for controlled substance prescriptions and may require periodic urine drug testing.
I understand that Dr. Rao does NOT participate in insurance plans. I understand that I am responsible for payment in full at the time service is rendered. Walls Down Wellness can provide a statement for patients to submit for insurance reimbursement.
I understand that Dr. Rao does NOT contract with MEDICAID (i.e., NJ FamilyCare Health Plans) or MEDICARE so she is unable to see patients with these benefits, even if they choose to pay out of pocket.
I understand that follow up appointment times are determined by Dr. Rao dependent on symptoms and treatment response. I understand Walls Down Wellness charges the following fees: *

-Initial Consultation (up to two hours): $750
-Follow ups up to 25 minutes: $250
-Follow ups up to 50 minutes: $500
I understand that follow up appointment times are determined by Dr. Rao dependent on symptoms and treatment response. I understand Walls Down Wellness charges the following fees: *
I have answered the questions about my (or my child’s) history above to the best of my ability. I understand that the initial appointment is a consultation and does not constitute continued care. If it is deemed that Walls Down Wellness cannot accommodate my treatment, I understand referrals will be given at the end of the initial consultation.
Admin Email
Admin Name
Should be Empty:

CONSULTATION REQUEST FORM

PATIENT CONTACT INFORMATION

PARENT CONTACT INFORMATION

PATIENT HISTORY

ACKNOWLEDGEMENTS