STARRY PSYCHIATRY & WELLNESS, PLLC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Billing & Payment

Payment method

How do you plan to pay?

Insurance Information ( Complete only if you plan to use insurance)

Please enter the name of your Insurance plan (e.g., Aetna, Blue Cross Blue Shield, Cigna, United healthcare, Optum, Carelon, Ascension, Medicaid etc.) . We will verify your insurance benefits before your appointment. If you are not currently in network with your insurance, we will contact you to discuss your scheduling and payment option before your visit.

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How did you hear about Starry Psychiatry & Wellness?

Google Psychology Today facebook Instagram Provider referral Other

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Is there anything that the practitioner needs to know before your appointment?

For example: what you'd like to focus on, insurance or payment questions, etc.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.