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NEW PATIENT FORM, Page 1 of 2 Welcome to Advanced Psychiatric Therapeutics appointment request form! We look forward to helping you. Please answer the questions below to assist us in establishing you with a provider.

PATIENT INFORMATION: *First Name: *Last Name: *Gender: Male Female Other: Prefer not to say *Phone Number (xxx-xxx-xxxx): *Address: Address (line 2): *City: *State: *Zipcode: *Email Address: *Date of Birth (mm/dd/yyyy): We noticed that the patient seems to be a minor. Please enter the contacting parent or guardian's contact information below. Parent/Guardian Name: Parent/Guardian Phone Number: Parent/Guardian Email: Were you referred by a specific provider? If so, who? Are there any other people that should be kept in the loop (Case Managers, Family Members, or another Provider)? If so, who? *Most Providers are seeing patients by Telehealth. Is this okay for you? Yes, telehealth is fine/preferable No, I would like to see someone in person *Would you like to be established with a particular provider? I would prefer to see whichever provider can see me first. I would like to select a specific provider. *Who would you like to establish with (you can click more than one)? Please see our Providers Page for more information. Please note, we can not guarentee that the provider(s) selected have availability, and we will only establish up to one Doctor/NP and one Therapist/Psychologist) Psychiatrists: Dr. Jeremy Roberts, MD Dr. Frederick Duennebier, MD (Adults and Children) Dr. Dean Fraser, MD Dr. Daniel Cho, MD Dr. Jacob Lee, MD Dr. Jeremy Richards, MD Therapists/Psychologists Dr. Bracken Gott, PsyD Ria Kim, LMFT Clay Wiggins, LCSW, CSAC Dr. Lauren Dawson, PhD, ABPP-CN Dr. Daniel Lev, PhD Dr. Olaf Gitter, PhD Chris Carter, LMHC Julie Segawa, LMFT