Book an Appointment Current Patients: Access the patient portal where you can add an appointment, make appointment changes, or cancel an appointment here: Patient Portal We are not currently accepting new patients.Please complete this form if you’d like to join our waitlist: Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### What services are you interested in? * Medication Management Therapy Med Management & Therapy Second Opinion Other Are you currently prescribed any psychiatric medications? * Yes No Not currently, but I have been in the past Have you ever thought about ending your life? * Yes, I currently have thoughts of ending my life. No Not currently, but I have in the past Will you be using insurance to pay for your appointment? * Please note that Willow Bend Psychiatric Care, PLLC does not accept Masshealth, Medicaid, or Medicare plans at this time. Yes, commercial insurance No, I'll pay out of pocket Do you give consent for the state Prescription Monitoring Program and Sure Scripts to be checked to review your current medications? * This is a requirement for all patients in the practice. Yes How did you hear about us? * Referred by family/friend Referred by therapist Referred by provider Alma Psychology Today Other How soon would you like to be seen? When taken off the waitlist and scheduled for an appointment it is our policy that if all intake paperwork and consents aren't completed within 72 hours of booking and receiving confirmation for this appointment - your appointment will be cancelled. I understand that if my intake paperwork isn't completed within 72 hours of appointment confirmation my appointment will be canceled and I can reschedule once my paperwork is completed. Please give any additional information you'd like to include. When an appointment becomes available would you prefer to be emailed or sent a text message to proceed with scheduling? * Please note: Email and text messaging are not secure forms of communication and may not fully protect your privacy. By choosing to be contacted via one of these methods, you acknowledge and accept these risks. Email Text message Thank you for your interest in care at Willow Bend Psychiatric Care. We’ve received your waitlist request and will notify you if an appointment becomes available.Please note that submission of this form does not guarantee future availability. If you would like to be contacted when a spot opens, you may choose to be notified via email or text message. Keep in mind that these methods are not secure and may not fully protect your privacy. By selecting one, you acknowledge and accept these risks.We appreciate your patience and understanding, and we wish you well in the meantime.
