Pax Mentis Psychiatry | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

Preferred method of contact

Phone calls Text message Email

State

I acknowledge that Pax Mentis Psychiatry only serves patients in CA and TX at this time.

Reason for care

In the past 2 weeks, have you had thoughts of harming yourself or others, or felt unable to keep yourself safe?

Yes No

What type of service are you seeking?

In the past 30 days, has your use of alcohol or other substances caused significant problems, or do you feel you may need more intensive treatment (such as detox or rehab)?

(example of problems: work, relationships, legal issues, or health)

Yes No

Are you seeking treatment for opioid use disorder or medication-assisted treatment (such as Suboxone/buprenorphine)?

Please note: Pax Mentis Psychiatry does not offer medication-assisted treatment (MAT) for opioid use disorder, including Suboxone/buprenorphine.

Yes No

Pax Mentis Psychiatry does not provide emergency or crisis services.

I understand this and will seek appropriate emergency or crisis care if needed.

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Billing & Payment

Are you currently enrolled in or covered by Medicare or Medicaid (including Medi-Cal, Medicare Advantage, or any Medicaid managed care plan)?

Please note: Pax Mentis Psychiatry is a self-pay practice and does not participate in Medicare or Medicaid. Due to federal and state regulations, we are unable to provide services to individuals who are enrolled in Medicare or Medicaid, even on a self-pay basis.

Yes No Not sure

Initial psychiatric evaluations start at $495.

Follow-up visits start at $225. Fees may vary based on time and clinical complexity.

I acknowledge Pax Mentis Psychiatry is a self-pay practice. Superbills are available for potential out-of-network reimbursement.

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.