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*

Current address? We are only able to work with residents of NY and FL. *

Who referred you? (therapist, pcp, other..please add name)*

Address associated with your insurance (if different from current address):*

Attach insurance & state ID

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