What are the main issues? Check all that apply: *

Anger

Anxiety

Behavioral Problems

Defiance/Opposionality

Depression

Eating/Body Image Issues

Moodiness

Check all of the following that are applicable: *

In therapy in the past

Attempted suicide in the past

Hospitalized for psychiatric reasons in the past

What kind of care is being sought? *

Medication

Therapy

Both

Are you currently prescribed and/or taking benzodiazepine medication (e.g., Xanax/alprazolam, Ativan/lorazepam, Klonopin/clonazepam)? *

Yes

No

Do you currently reside within South Carolina? *

Yes

No

Patrick Wiita, MD does not participate in insurance plans. I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made. I will be provided a statement so I may try to get some reimbursement from my insurance company if I am eligible. *

Yes

No

I understand that Dr. Wiita does not accept insurance and that payment is due at time of service. Credit card information will be stored securely by a third-party processing service and you will be charged automatically for services according to the treatment agreement. Dr. Wiita cannot see patients who are Medicare or Medicaid beneficiaries. *

Yes

No

Patrick Wiita, MD is a self-pay only practice. The initial evaluation with Dr. Wiita is $1,000 and follow-up appointments are $275. We do not file anything directly with your insurance. Please check with your health insurance provider regarding your Out-of-Network benefits. Do you accept the fees and self-pay policy? *

Yes

No