Spectrum Psychology & Wellness New Patient Pre-Screening Get started by filling out the form below! "*" indicates required fields Patient First Name* First Name Patient Last Name* Last Phone*Email* Date of Birth*Insurance Provider (e.g. Blue Cross Blue Shield)*Insurance ID Number/Policy Number*Is the potential client a minor?*Please SelectYesNoAre the biological parents residing together? Yes No Parent Name* Parent First Name Parent Last Name Parent Phone*Parent Email* Brief Reason for Coming In*Relationship Counseling Select this if you are coming in for a form of relationship counseling How many partners are coming in for relationship counseling?* 1 other than me 2 other other than me More than 2 others than me Partner Name* First Last Partner Phone*Partner Email* Partner Insurance Provider (e.g. Blue Cross Blue Shield)*Partner Insurance ID Number/Policy Number*Date of Birth*Partner 2 Name* First Last Partner 2 Phone*Partner 2 Email* Partner 2 Insurance Provider (e.g. Blue Cross Blue Shield)*Partner 2 Insurance ID Number/Policy Number*Date of Birth*You have selected 2 or more partners. Please contact the office directly.This field is hidden when viewing the formPlease Select Provider*Rebbeca Lahann, Psy.DRachel Jensen, Ph.DMonika Peterson, Ph.DLeslie O’Neill, Ph.DBryan Gaviria-Jimenez, Psy.DMercedes Anderson, Ph.DJeff Lahann, MBANo PreferencePlease Select Provider* Adalesa Meek, LPC Sarah Koop, LPC Rebbeca Lahann, Psy.D Leslie O’Neill, Ph.D Bryan Gaviria-Jimenez, Psy.D Mercedes Anderson, Ph.D Indra Gonzalez, Psy.D Jeff Lahann, MBA No Preference It may take some time to get you scheduled with your preferred provider. We are not a crisis care facility. If you feel you are in crisis and need to be seen urgently, please call 911 or 988, or call the EMPACT crisis hotline at 480-784-1500 for assistance. Please note, our office does not provide court ordered, alcohol or substance abuse or medication management services.
