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• Making OnLine Referral

Application Form for Self-Referred Private Patients Only

Dr. Adams accepts self-referred private patients on a very limited basis.  He reviews your request for consultation and verifies by e-mail before he agrees to see you. If he cannot, or elects not, to see a specific patient, he will redirect you to the State psychological association.

In order to determine if this is the most appropriate practice in which you should be seen, please complete the following initial contact form. All fields must be completed. This form must be submitted only by the prospective patient. The form is reviewed by no one other than Dr. Adams. Referrals are not accepted from friends or relatives of the prospective patient.

If you are accepted as a patient, the fee per (45 minute) visit for individuals is $150. The initial visit is $300 (90 minutes) and requires brief psychodiagnostic assessment and taking your history.

Dr. Adams cannot respond to the volume of individual/personal questions sent to him.  He strongly recommends that you avail yourself of the online Discussion Groups located here at psychological.com.

If you are referring a workers' compensation patient, you should go to the workers' compensation form.

After you complete the following form, click SUBMIT (once), you will receive a confirmation message, and the office will contact you at our earliest convenience.  Do not telephone the office until your have completed, and we have responded, to this application.

Reminder: All fields must be completed

Title:    First Name:  Last Name:     Age

Male  Female  

Marital Status (currently) Single  Married   Separated  Divorced  Widowed

Address:  City:  State:  Zip: 

Office phone:  Home phone:  Cell phone: 

Your e-mail address:

Highest Educational Level: 

Occupation:

Problem Areas (please check all that apply):

Mood Anxiety Phobia(s) Physical Complaints Sleep Disorder Eating Disorder
Marital/Relationship Problems Sexual Problems/Dysfunction  Impulse Control Drugs and/or alcohol

I am currently in ongoing treatment:  Yes  No

I have been in treatment in the past:  Yes  No

I am currently on medication:  Yes  No

I have been hospitalized for my problems in the past:  Yes  No

Describe your current problem(s) in detail:

 

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©2006 David B. Adams, Ph.D.