MTI PSYCHIATRY | SimplePractice

MTI PSYCHIATRY Send Message

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Obsessive Compulsive issues Psychosomatic issues Second opinion Other

What kind of care is being sought?

Psychotherapy only Medication only Psychotherapy and Medication Second opinion consultation Other Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Administrative

Referral source

Where did you learn about our services? (e.g., Referral, friend, google search)

Billing & Payment

Payment method

Dr. Ingram does not accept insurance. Do you plan to pay out of pocket?

Dr. Ingram has opted out of Medicare.

I am not using Medicare coverage.

Have you reviewed Dr. Ingram's rates for initial consultation and follow up? If not, please visit https://michaeltingram.com/practice-policies

Yes, I have reviewed Dr. Ingram's rates, and I would like to proceed. No

Client Preferences

Is there anything that the practitioner needs to know?

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

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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