Request an Evaluation Δ Name(Required) First Last Relationship to patient(Required) Self Parent Partner Friend/Family Caretaker Other Other relationshipPatient Name(Required) First Last If the patient is a child, what is their age?Email(Required) Please provide the contact information for the person that will be making the appointment.Phone Number(Required)Please provide the contact information for the person that will be making the appointment.What is the best time to reach you?(Required) Morning Midday Evening What is your preferred method to be reached?(Required) Phone call Text message Email Dr. Alessi will follow up with you within 24 hours of inquiry.Select your primary condition(s) for visiting.(Required) Depression Treatment Resistant Depression Anxiety Attention Deficit Hyperactivity Disorder (ADHD) Dissociation Autism Spectrum Disorder (ASD) Post Traumatic Stress Disorder (PTSD) Substance Abuse Obsessive Compulsive Disorder (OCD) Trauma Other Other reasonBriefly describe any previous treatment you have had(Required)Are you currently undergoing treatment?(Required) Yes No Have you been previously hospitalized?(Required) Yes No Are you currently perscribed any medications?(Required) Yes No Please share any associated medical illnesses you have (e.g. headaches)(Required)Do you have a seizure disorder or any other neurological conditions?(Required) Yes No Please explain your symptoms(Required)What kind of assistance are you looking for from Dr. Alessi?(Required) Medication management Psychotherapy Second opinion Evaluation Are you interested in ketamine treatment?(Required) Yes No Unsure What type of ketamine treatment are you interested in?(Required) Medication only Medication-assisted psychotherapy Trauma integration Unsure what is best for me Dr. Alessi does not accept insurance. Prices listed are ranges of costs you may encounter: Evaluation $600 – $1,800; Treatment $1,200 – $3,000; Ketamine $1,400 per session(Required) I acknowledge Dr. Alessi does not accept insurance, and I will pay out-of-pocket for all sessions. Check this box to indicate you are willing to pay out-of-pocket, and that you will handle any reimbursement claims yourself.Any other questions or concerns for Dr. Alessi?