Name
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First Name
Last Name
Date of Birth
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Email
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Phone
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Preferred Method of Contact
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Check all that apply.
Will you be using insurance?
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Please note: I currently do not accept Excellus BCBS or MVP plans, but can provide a superbill for services. I do not accept medicaid or medicare managed plans through any insurance at this time.
Do you have any regular schedule conflicts?
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Such as days or times you absolutely cannot schedule.
Do you prefer appointments to be in-person or virtual?
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At this time, I am unable to prescribe controlled substances without an in-person session.
What services are you interested in?
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Please check all that apply.
If you selected 'Other', please specify what other services you are looking for:
What are you looking to address?
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This may include depression, anxiety, ADHD, self-esteem, body image, life transitions, women's health issues, or other mental health challenges.
Are you currently engaged in any mental health treatment?
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Please list any current medications you take, including psychiatric and medical medications, vitamins, supplements, etc.
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Have you had any inpatient mental health hospitalizations within the last three months?
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If you answered 'Yes', please provide more information:
Are you currently having suicidal thoughts?
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If you are having suicidal thoughts and there is immediate concern for your safety, please call or text 988 (Suicide and Crisis Lifeline).
Do you use any substances on a regular basis that you or anyone have considered to negatively impact your life?
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This includes alcohol, marijuana, amphetamines, cocaine, opiates
If you answered 'Yes', please provide more information:
Anything else you'd like me to know before following up with you?
How did you hear about Stacey M. Perrotta, NP?
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Psychology Today
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Referral
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If you selected 'Referral' or 'Other', please specify referral source:
