Welcome to ZenzyTalk! We are excited to be a part of your mental wellness journey to help you become the best version of yourself. This form is for a 60 min initial psychiatric evaluation, followed by 30-45 minutes medication management sessions for psychiatry. Frequency of follow-up sessions vary based on your treatment plan, at least monthly to every three months. We are a NY and FL based practice only. *In-person visits upon availability.

Name*

Date of Birth*

phone number*

Email*

Which state/city are you located in? We are only able to work with residents of NY and FL. *

Address associated with your insurance:*

If out of network, would you need to pay out of pocket?

Are you open to seeing one of our Psychiatric RN clinical interns?

Attach insurance and state ID

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