Schedule Consultation

Clinician's First Name (required)

Clinician's Last Name (required)

Specialty (required)
PediatricianFamily PhysicianAPNInternistOB/GYNPsychiatristAdult PsychiatristChild PsychiatristSocial WorkerNurseOther Non-prescribing Mental Health ProviderOther Non-prescribing Health Provider

Practice Type (required)
Community Mental Health CenterFederally Qualified Health CenterPrivate PracticeSchoolOther, please specify (text)

If other, specify here

Name of Facility/Practice (required)

Street Address line 1 (required)

Street Address line 2

City

Zip Code

State
IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Phone Number (required)

Best time for a consultation (required)
(Example: 1pm - 3pm Tuesday, June 6th)

Email (required)

Request Type (required)
---General QuestionPatient Specific Question

Problem type: (Check all that apply)
Acute Stress Disorder (ASD)ADHDAdjustment DisorderAggressionAnxiety DisorderAutism Spectrum DisorderBinge eating/purgingBullyingChild/adolescent resistance to mental health treatmentCommunication Disorder Includes Social Communication DisorderConduct DisorderDevelopmental concernsDevelopmental Coordination DisorderDisruptive Behavior DisorderDisruptive Mood Dysregulation Disorder (DMDD)Eating DisorderEncopresisEnuresisFamily Problems- economic (i.e. loss of job, chronic un-employment, underemployment)Family problem(s) (i.e divorce, relational problems etc.)Foster care ward of the stateFussy Baby SyndromeGay/Lesbian/ bisexualGeneralized Anxiety DisorderGrief/lossHFS/Medicaid prior authorization problemsIntellectual DisabilityMedication Assisted Therapy (MAT) for pregnant womenMedical illness (specify)Medication side effectMood Disorder - BipolarMood Disorder – DepressionObesity/weight-relatedOCDOppositional Defiant DisorderParent child relation conflictParenting problemParent resistance to mental health treatmentPersonality DisorderPost-PartumPosttraumatic Stress DisorderPrenatalProperty destructionRestrictionSchizophrenia/Other Psychotic DisorderSchool Problem (s)School refusalSelf-harm/cuttingSensory SensitivitySeparation ConcernSexual acting outSexual/Gender Identity DisorderSleep problemsSocial Phobia (Social Anxiety Disorder)Specific Learning DisorderStereotypic Movement DisorderSubstance-Related DisorderSuicidalityTrauma/AbuseTraumatic brain injury

Insurance
AllKidsDCFS PaymentMedicaidManaged Medicaid ProviderPrivate Insurance PPOPrivate Insurance HMOOther, specify

If other, please specify

How did you hear about us?
Attended an IL DocAssist workshop/webinar please specify (text field)Encouraged to use the service by a colleagueIL DocAssist websiteFlyer/BrochurePromotional item (pen, magnet, hand sanitizer)Trade organization newsletterHFS websiteProfessional conferenceHospital intranet pageOther, please specify below

Reason for consultation. Check all that apply
ScreeningDiagnosingGeneral management of conditionInitiating medicationOngoing medication managementReferral assistanceInformation on Motivational interviewing/Brief interventionOther Specify, please do not include identifying information (HIPAA)

If other reason for consultation, short description
(please do not include identifying information (HIPAA))