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Please read carefully before completing this form:

This form is used to determine eligibility for psychiatric services. This practice provides outpatient medication management only. Completion of this form does not establish a provider–patient relationship and does not guarantee evaluation or acceptance into the practice. Only individuals who meet established clinical and administrative criteria will be asked to proceed. Incomplete, inaccurate, or inconsistent information may result in denial of the request. Due to high demand and to maintain quality of care, follow-up inquiries regarding the status of prescreening submissions may not receive a response. This practice provides outpatient medication management only. We do not treat substance use disorders, as these require a higher level of care. This is not an emergency service and we do not offer urgent or same-day visits, have providers on call, and handle all patient requests during business hours ONLY. If you are experiencing a psychiatric emergency or thoughts of harming yourself or others, call 988 or go to the nearest emergency room immediately. Practice Information & Policies Visit Types: Megan Resnick, NP in Psychiatry, PC offers both telepsychiatry (virtual visits) and limited in-person visits. In-person visits are available bi-weekly on Tuesdays and Fridays only In-person appointments may be converted to telehealth at the provider’s discretion Hours of Operation: Monday: 10:00 AM – 6:00 PM Tuesday: 9:00 AM – 6:00 PM Wednesday: Closed Thursday: 8:30 AM – 12:00 PM Friday: 9:00 AM – 2:00 PM Saturday/Sunday: Closed Please ensure that these hours align with your availability. After-hours appointments are not available. Urgent & Emergency Care: At this time, there is no on-call provider, and the practice is unable to accommodate urgent or emergency appointments. If you are experiencing an emergency, please call 911, go to the nearest emergency room, or contact 988. Financial Policy: A valid form of payment is required on file at all times Copays are due at the time of service Patients must remain in good financial standing to continue care Cancellation Policy: We strictly enforce our cancellation and missed appointment policy, including applicable fees. Communication: All correspondence regarding your intake request will be sent to the email address provided.

Person Completing Form
How did you find us?
Provider Request
Reason for evaluation
Adjusting or optimizing current medications
ADHD evaluation
Assessment of substance use
Continuing care
Court-ordered or legal evaluation
Coping skills and stress management
Disability/ FMLA documentation
Diagnostic clarification or second opinion
Fitness-for-duty evaluations
Grief or loss
Life transitions or situational stress
Mental health evaluation related to a medical condition
Medication management (start, adjust, or refill)
New onset symptoms
Perinatal or postpartum care
Pre-surgical psychological evaluations
Pre-treatment or baseline assessment
Safety assessment / urgent concerns
Stress management and coping skills
Therapy / counseling support
Work or school accommodations
Are you experiencing a mental health crisis?
Symptom Severity:
Functioning:
Do you have a previous/active psychiatric diagnosis?
Have you had any thoughts, attempt, or plan of harming others in the last 3 months?
Have you ever engaged in self-harm or self-injurious behaviors, currently or in the past?
Do you have a history of violence/aggression/ behavioral problems/ legal troubles?
Do you take any psychiatric medications?
Insurance

Your request will be reviewed and we will be in touch! If you have other questions or would like to discuss private fee rates or out-of-network benefits, please email us directly at Adminws3@claritymbwellness.com

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