Name of Patient *

First Name

Last Name

Patient's Phone Number *

(###)

###

####

If we are unable to reach you, may we text you to coordinate a time to talk? *

Yes

No

Please acknowledge each of the following statements before sending this form: *

Dr. Maldonado, like most psychologists in the community, is in high demand. We want to help as many people as possible and have limited time to do so. We do not overbook our doctor and thus scheduling an appointment is a commitment. When you book your initial appointment a credit card will be required. We will charge the full fee for any missed appointment unless the appointment is canceled or rescheduled with 24 hours or greater notice.

I acknowledge

*

Dr. Maldonado is in-network with many, but not all, plans under the following insurance networks: Aetna, Blue Cross and Blue Shield, United Healthcare/United Behavioral Health, Community First-University Family Care Plan, Cigna, and Medicare. Dr. Maldonado is not in-network with Medicaid or Humana plans. Please call the Member Services number on the back of your insurance card BEFORE sending this form in order to verify that Dr. Maldonado is in-network with your specific insurance plan and inquire about any deductibles and copay/coinsurance amounts that may apply. While we do submit insurance claims on your behalf, it is your responsibility to verify your coverage details and pay any amount not covered by your insurance plan.

I acknowledge

*

Submitting a message through this contact form is a helpful first step, but it does not establish a professional or therapeutic relationship. A formal psychologist-patient relationship begins only after we’ve spoken directly and completed all required intake procedures, including informed consent. If you are in crisis or need immediate support, please contact 911 or 988, the National Suicide and Crisis Lifeline. I look forward to connecting with you soon.

I acknowledge