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Ashley Bouzis, MD

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New Patient Appointment Request

New Patient Appointment Request

Please note, completing this form is a request for consultation and does not establish a doctor:patient relationship.

Name

Gender

Email

Date of Birth

Pronouns

Phone

What is the main reason you are seeking treatment?

Please check any of the following that apply to you. *

In therapy now

In therapy in the past

In the hospital now

Hospitalized for psychiatric reasons in the past

On psychiatric medications currently

Taken psychiatric medications in the past

None of the above

Currently experiencing suicidal thoughts

Attempted suicide in the past

Current of past self-harm

None of the above

Please provide additional detail on the above.

Thanks for submitting!

© 2019 by Ashley Bouzis

Ashley Bouzis is a psychiatrist, psychotherapist, therapist and yoga teacher in Seattle, WA

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