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Intake Screener for Anxiety Reset Psychotherapy LLC

All services are offered via telehealth. This form is not to be used for emergency or urgent matters. Please call 911 for local emergency services or present to your closest emergency room.

By proceeding, you are affirming that this is not an emergency or urgent matter.

By proceeding, you are also affirming that you understand that Dr. Anahvia Moody/Anxiety Reset Psychotherapy LLC does not treat the following conditions due to the limitations of telehealth practice:

-Psychiatric hospitalization within the past 5 years
-Personality disorders (e.g., antisocial, narcissistic, borderline)
-Frequent and/or severe suicidal ideation
-Bipolar disorder, mania, or hypomania
-Psychotic spectrum disorders (e.g., schizophrenia, schizoaffective, paranoia, etc.)
-Substance use disorders.

I would like to proceed. This concern is not an emergency/urgent and none of the above conditions apply to me. One or more of the above conditions apply to me, and/or this concern is an emergency or urgent matter. (Please close out of this form and call 911 for emergencies. Additionally, If one of the above conditions apply to you, our practice cannot serve your needs.)

First Name

Last Name

Date of Birth

Current Home Address (e.g., 123 Main St, New York City, New York, 12345)

How were you referred to this practice (e.g., Internet search, Psychology Today, by a specific provider (please include their name), word-of-mouth, etc.)?

Anxiety Reset Psychotherapy LLC focuses on anxiety- and obsessive-compulsive-related conditions such as generalized anxiety, social anxiety, panic attacks, phobias, obsessive compulsive disorder (OCD), body dysmorphic disorder (BDD) and other body image concerns, and trauma (including posttraumatic stress disorder/PTSD). We also treat insomnia/sleep difficulties. As an affirming practice, Anxiety Reset Psychotherapy LLC welcomes individuals who have LGBTQ-, race-, disability-, and/or other minority-related stress and trauma as well. Even if you are unsure if your concerns align with the services we offer, please continue with this form and we’ll be happy to discuss with you further.

Please briefly describe the primary concern for which you are seeking therapy:

I understand that all visits will be held live via a HIPAA-compliant audio-visual telehealth platform (Sessions Health). I have a stable Internet connection (Wi-Fi or data) and a device that connects to camera and microphone.

Yes No

Anxiety Reset Psychotherapy is in-network with some insurers (including the federal employee program/FEP). Please verify your behavioral health insurance benefits to ensure you can access the national network of providers via telehealth. You can find the most up-to-date list of insurance plans accepted online (anxietyresettherapy.com/FAQ). Dr. Moody is happy to assist with verifying your benefits. We accept out-of-network/private pay clients. You will be provided with a “superbill” after each session so you can try to receive reimbursement for out-of-network services from your insurance company. Out-of-network or private pay clients are responsible for the full session fee (located on our website: anxietyresettherapy.com/FAQ and in your consent form). We do not accept Medicare, Medicaid, TRICARE, CHAMPVA, or any other government insurer. Dr. Moody is happy to assist with referrals if you have one of these government insurers as primary or secondary. By signing, you understand that you are responsible for either payment in full or your co-pay at the time service is rendered. You understand that it is your responsibility to verify your benefits for psychotherapy with your insurance company, and to specifically ask them about telehealth psychotherapy visits. Service fees can be found in your signed consent form and online: anxietyresettherapy.com/FAQ.

Please acknowledge that you understand and agree to these conditions.

Yes No

Thank you for completing this brief intake screener. The above information will be reviewed, and Dr. Anahvia Moody will contact you to discuss whether your needs are a good fit with the services this practice provides. Please provide an email address and phone number for contact. If contacted by email, you will be notified that you’ve received a secure email. Click “view message” and you can set a password and password hint phrase to view this and all future emails from this practice. Be sure to check spam/junk folders if you do not see a response in your inbox within 3 days.

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