INTEGRATIVE PSYCHIATRY & PSYCHOTHERAPY

Provider Forms

For Dr. Myers, Dr. Sanders and Ms. Irizarry:

EXISTING PATIENTS: If you will be using our web-based teleconferencing services,  please complete this form only and return it to us by fax or U.S. mail:

     —Teleconferencing Consent Form

NEW PATIENTS: Please complete all four of these forms as well as the forms for your specific provider, below, and return them to us by fax or U.S. mail:

     —Teleconferencing New Patient Form

     —Teleconferencing Insurance Benefits Assignment Form

     —Teleconferencing Office Policies and Procedures

     —Teleconferencing Consent Form

For Dr. Myers (please complete all forms):

     —Intake Form #1

     —Intake Form #2

     —Intake Form #3

     —Intake Form #4

For Dr. Sanders (please complete one form):

     —Intake Form, Child/Adolescent

     —Intake Form, Adult

For Ms. Irizarry (please complete both forms):

     —Intake Form #1

     —Intake Form #2

© INTEGRATIVE PSYCHIATRY & PSYCHOTHERAPY PLLC 2019

INTEGRATIVE PSYCHIATRY

& PSYCHOTHERAPY  PLLC

161 Magnolia Square Court

Aberdeen, NC 28315

(910) 757-0714 (phone)

(910) 757-0703 (fax)