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Psychiatry

$240

Initial Visit

$120

Follow Up

Therapy

$150

Initial Visit

$150

Follow Up

Please fill in the form below.

Personal details

Legal First name*

Legal Last name*

Mobile*

Email address*

Gender at birth*

Referred by*

Date of birth*Address*

City*

State*

Zip code*

Emergency Contact Name*

Phone No

Emergency Contact Relationship

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Name of person completing form and relationship to patient*Reason for appointment*Current medications and dosage*List any medical allergies*Primary Care Physician (Name, Phone, Address)Type of appointment

Psychiatry - Adult

Psychiatry - Pediatrics

Therapy

Are you using insurance?*YesNo

Insurance provider*Insurance ID*Group #(if applicable)Please upload a picture of the front and back of your insurance card.

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Preferred Pharmacy

Name

Phone No

Address

City

State

Zip

Is patient a minor?*YesNo

Is patient a minor?*

Legal Guardian(s) (if applicable)

Preferred Phone No

CellHomeWork

Secondary Phone No

CellHomeWork

Email AddressPatient/Guardian's Name

Patient/Guardian's Signature

Date

Do you have any current or pending legal issues or are being advised by a court judge,parole officer, or CPS to seek mental health care or assessment?*YesNoPlease select if you have ever experienced or suffered from any of the following in the past or present? (check that applies)
Have you had thoughts of harming yourself?*PastCurrentlyNeverHave you had thoughts of harming others?*PastCurrentlyNeverHave you struggled with alcohol abuse?*PastCurrentlyNeverHave you struggled with substance abuse?*PastCurrentlyNeverConsentI agree to the TeleMed2U Terms & Conditions, Telehealth Consent, Privacy Policy and Notice of Privacy Practices, and understand all of these can be accessed at any time on telemed2u.com.By submitting this form, I agree to receive SMS messages related to my healthcare, including appointment updates and care coordination. Message frequency may vary. Msg & data rates may apply. Reply STOP to unsubscribe.

Disclaimer: Self-paying patients have to pay their balance prior to their appointment.

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Contact Us

3400 Douglas Blvd.
Suite 170 Roseville, CA 95661

Phone:
(855) 446-8628

Email:
info@telemed2u.com

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If you are actively in crisis, please call or text 988 for the Suicide & Crisis Lifeline. TeleMed2U does not provide emergency or crisis services. By continuing, you acknowledge and consent that you understand TeleMed2U is not a crisis response provider.

TeleMed2U does not provide specialized treatment for Alcohol Use Disorder.

Our clinicians can support underlying behavioral health needs, but we are unable to treat, manage, or prescribe for alcohol misuse. For help with alcohol use, you can contact the SAMHSA National Helpline at 1-800-662-HELP (4357), available 24/7. By continuing, you acknowledge that you understand TeleMed2U cannot treat Alcohol Use Disorder.

TeleMed2U does not provide specialized treatment for Substance Use Disorders.

Our clinicians can support underlying behavioral health needs, but we cannot treat, manage, or prescribe for substance use. For support, you can contact the SAMHSA National Helpline at 1-800-662-HELP (4357), available 24/7. By continuing, you acknowledge that you understand TeleMed2U cannot treat Substance Use Disorders.