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Psychiatry/Medication Management Inquiry FormMarc Joseph2023-07-26T16:15:41-04:00

Psychiatry/Medication Management Inquiry

"*" indicates required fields

Which Location?*

Name

First Last

Date Of Birth:

MM slash DD slash YYYY

Phone:

Email:

Address

Street Address City State ZIP Code

Do you have Insurance?

Yes

Primary Insurance:

Primary Insurance ID:*

Do you have Secondary Insurance?

Yes

Secondary Insurance:

Secondary Insurance ID:*

What medications are you currently prescribed:*

Do you currently have any of the following providers?

A Primary Care Doctor?

Yes

A Psychiatrist?

Yes

A Therapist?

Yes

How did you hear about us?

Internet

Social Media

Psychology Today

Word Of Mouth

Medical Provider/Hospital

Other

Which Medical Provider/Hospital?

Other - Please explain:

Primary Care Doctor (Full Name):

Doctor Phone Number:

If Yes and seeking therapy services with Bishop Health, why are you leaving your current provider?

Current Psychiatrist (Full Name):

Psychiatrist Phone Number:

If Yes and seeking psychiatry services with Bishop Health, why are you leaving your current provider?

Therapist (Full Name):

Therapist Phone Number:

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Bishop Medical Group offers outpatient addiction & psychiatric services for clients in Portland, ME and the surrounding areas.

Contact Details

100 Gannett Dr
Suite A
South Portland, ME 04106
(888) 280-2585
[email protected]

Admissions: (888) 280-2585
[email protected]

Portland, Maine

100 Gannett Dr Suite A South Portland, ME 04106
(888) 280-2585
[email protected]

100 Gannett Dr
Suite A
South Portland, ME 04106
Office: (207) 742-8558

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