Confidentiality Notice: This form is hosted on a platform that is not HIPAA-secure, which means any information you share here could be visible outside of our encrypted systems. While your responses are stored securely once they reach our Google Workspace (covered by a Business Associate Agreement), the initial submission itself is not protected under HIPAA. Please avoid including personal medical history, diagnostic information, or medication details. You’re welcome to share what kind of support you’re seeking, your pronouns, and which provider you’d like to work with — and we’ll follow up through our secure patient portal for anything private.

Yes, I understand

Name *

Put what you go by. It doesn't have to be what's on official documents.

First Name

Last Name

Phone

(###)

###

####

What services are you interested in?

Psychiatric Care

ADHD/Autism Assessment

Gender-Affirming Care

Perimenopausal Care

Peripartum Psychiatry

More than one of these

Do you have a specific provider in mind? *

No preference/I'm not sure

Jess Romeo

Janine Michaelson

Teresa Vlahovich

Tina Remillard

I understand that OutPsych is an out-of-network practice that does not take insurance. I have reviewed the FAQ page with information about how to anticipate out-of-pocket costs and contact my insurance with questions.

Yes, I understand

I need to use my insurance or discuss sliding scale care