Let’s work together Name * Please note: Keighley does not accept requests from individuals reaching out on behalf of someone else. First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Will you be using insurance? * Note: Keighley accepts commercial insurance plans through Excellus/BCBS. She does not accept insurance plans with the prefixes VYT, VYH, VYB, YNC. Individuals with Medicaid CANNOT be seen via self-pay. Yes, I will be using Excellus/BCBS No, I will be doing self-pay Do you prefer in-person or virtual appointments? * In-person Virtual What services are you looking for? * Psychiatric medication management Other What concerns are you looking to address? * Note: Keighley offers treatment of depression, anxiety, obsessive-compulsive disorder, and post-traumatic stress disorder. She DOES NOT treat ADHD or bipolar disorder. Anxiety Depression Obsessive-compulsive disorder Post-traumatic stress disorder Please list ALL current medications and doses including vitamins and supplements: * Are you currently seeing a therapist? * Yes No Do you have a history of inpatient hospitalization for mental health concerns? * Yes No Are you currently having any thoughts of suicide? * Note: this practice does not provide emergency services. If you are having thoughts of suicide and there is concern for your safety, please call or text 988 (Lifeline/Mobile Crisis Team), call 911, or go directly to the nearest emergency department. Yes No Do you have a history of substance use (present or past)? * Note: this includes alcohol, marijuana, amphetamines, cocaine, opiates, etc. Yes No Please provide any additional information you would like Keighley to know: * How did you hear about Keighley Loveland? * Google Search Psychology Today Insurance Provider Tree of Hope Therapist Primary Care Provider Family/Friend Other Thank you for your interest! You can expect a response from Keighley via email within 3-5 business days.
