Name *

First Name

Last Name

Phone *

(###)

###

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Psychiatric history (check all that apply) *

Currently on psychiatric medications

Was previously on psychiatric medications

Currently in talk therapy

Was previously in talk therapy

At least one life time psychiatric hospitalization

Psychiatric hospitalization/ED/Urgent care visit within past 6 months

History of suicide attempts

Known neurologic, genetic, developmental disorder

None of the above

Payment and fees *

I understand Dr. Lydia Kim does not contract with any insurance companies. Dr. Kim will review fee structure prior to services. Payment is due at the time of services rendered. I can request an itemized bill/superbill to submit to my insurance company for (partial) reimbursement. I am responsible for understanding the specifics of my insurance plan.

Yes

No

Payment processing *

All patients are required to have a credit care on file with a secure, HIPPA-compliant payment processing platform. Dr. Kim will discuss fees in advance of the appointment and will charge the credit card on file if payment is not completed through other means. Dr. Kim does not see or store my credit card information.

I agree

I disagree