Frequently asked questions
How this practice works, what the treatments people ask about actually are, and where to turn if you cannot wait for an appointment. This page is general information, not medical advice, and reading it does not begin a physician–patient relationship.
Deciding to come in
Whether a psychiatric consultation is the right next step, and what the first few weeks tend to look like.
How do I know if I should see a psychiatrist?
A psychiatrist is a physician who completed medical school and a residency in psychiatry, and who is trained to read psychiatric symptoms in the context of the whole body. Medication effects, thyroid and other endocrine disease, sleep disorders, substance use, neurological illness and chronic pain all change the psychiatric picture, and sorting that out is a large part of the work.
Reasonable prompts to seek an evaluation include:
- symptoms lasting more than a few weeks that interfere with sleep, work, school or relationships;
- two or more medication trials that have not worked;
- a diagnosis that has shifted several times, or never quite fit;
- side effects that are hard to tolerate, or a complicated regimen you would like reviewed and simplified;
- a first episode severe enough that getting the diagnosis right from the start matters.
Many people are treated well by a primary care physician or a psychotherapist and never need a psychiatrist. A psychiatric consultation can also be a single second opinion rather than ongoing care — a fresh diagnostic formulation and a written plan sent back to whoever is already prescribing.
If you are in immediate danger, do not wait for an appointment. See What if I have an emergency? below.
How do I become a patient?
In most private psychiatric practices the sequence is the same: you send an enquiry, there is a brief screening conversation to establish whether outpatient care here is the right level of care for what you are dealing with, and only then is an initial evaluation scheduled. The screening step exists to protect you as much as the practice — someone who needs a higher level of care is not served by a first appointment three weeks out.
[Describe your actual intake path end to end: whether first contact is the form on /contact.html, a phone line, or a referral from another clinician; who answers it and within what timeframe; whether there is a free brief screening call before booking; what you screen for (diagnosis, acuity, whether the patient is safely treatable in outpatient private practice); and what you tell people you cannot take. More prospective patients are lost at this step than at any other, and a written screening standard is also your documentation that you did not accept someone whose acuity exceeded this setting.]
Start at Get in touch. Please keep clinical detail out of that first message — email and web forms are not secure.
What happens at the first appointment?
An initial psychiatric evaluation is a long, structured conversation. It generally covers the history of the current problem and how it has changed over time; previous episodes; every medication tried, at what dose, for how long, and why it was stopped; sleep, appetite, energy, concentration and substance use; medical history, current medications and supplements, and relevant family history; and a direct discussion of safety. Where it is useful, it includes standardised rating scales so that change can be measured rather than recalled, and a review of prior records, laboratory results or imaging.
You should leave with a working diagnosis stated plainly, an explanation of the reasoning behind it, the alternatives that were considered, and a specific plan with a defined point at which it will be reassessed. If the honest answer at the end of the first visit is that more information is needed, that is what you should be told.
[State the length and format of your initial evaluation (for example 90 minutes, in one session or two), what you ask patients to complete or bring beforehand — intake forms, symptom scales, a records release, a medication list, prior trials — and whether records from previous prescribers must arrive before the visit. Patients arrange childcare and time off work around this answer, so it needs a real number.]
How often will we meet?
Visit frequency follows the clinical situation rather than a fixed schedule. When a medication is being started, changed or tapered, visits are closer together, because that is when side effects appear and when early response or non-response becomes visible. Once things are stable, intervals lengthen. Most treatment guidelines expect a meaningful trial of an antidepressant to run six to eight weeks at an adequate dose before it is called a failure, which shapes how the first few months are spaced.
[Give your usual cadence and visit lengths — for example every two to four weeks while a medication is being adjusted, then every six to twelve weeks once stable — and state the maximum interval you will allow between visits while continuing to prescribe. If refills are tied to having been seen within a defined window, say so here and make the wording match the refill answer under Practical matters.]
Do you offer telehealth or in-person visits?
One point of law is worth understanding before you plan around telehealth: a physician must hold a licence in the state where the patient is physically located at the time of the visit, not where the physician sits. A patient who moves, or who is travelling for a month, cannot simply keep their video appointments unless the physician is licensed in that state. Prescribing controlled substances by telemedicine is governed by a separate and still-shifting set of federal rules; see the controlled substances question below.
[State plainly which visits are by video and which are in person, whether the initial evaluation must be in person, and every state in which you hold an active licence. Name the video platform you use and confirm a signed business associate agreement is in place with the vendor — consumer video tools without a BAA are not an acceptable substitute.]
What ages do you see?
Scope of practice matters here. General adult psychiatry, child and adolescent psychiatry, and geriatric psychiatry differ in training, in the evidence base, and in the medications and doses that are appropriate, so practices are usually explicit about the age range they accept.
[Give the age range you accept — for example adults 18 and older — and say whether that includes older adolescents, college students or geriatric patients. If you do not treat children, say so directly rather than by omission: it saves families a call and it documents that you are not practising outside your scope.]
What it costs and how it is billed
Out-of-network billing, superbills, and the written estimate you are entitled to before care begins.
Do you take insurance?
Private psychiatric practices fall into one of three arrangements, and the difference matters to what you pay. A practice may be in network with a plan, in which case you pay a copay and the practice bills the insurer directly. It may be out of network, in which case you pay the fee at the time of the visit and may seek partial reimbursement from your plan yourself using a superbill. Or it may be cash-pay only, with no claims submitted at all. Medicare is a separate question from commercial insurance and follows its own rules.
[State whether you are in network with any commercial plan, out of network with all of them, or a mix — and separately state your Medicare status, which is the item private practices most often get wrong. A physician who is neither enrolled in Medicare nor formally opted out generally cannot be paid privately by a Medicare beneficiary for covered services, so if you intend to be cash-pay, confirm your opt-out affidavit is on file and describe the private contract beneficiaries must sign. Also say whether you will submit out-of-network claims on the patient's behalf or only supply a superbill.]
If you have a plan with out-of-network benefits, call member services before your first visit and ask three questions: is there an out-of-network outpatient mental health benefit, what is the out-of-network deductible and how much of it have I met, and what percentage of the allowed amount is reimbursed once it is met.
What are the fees?
Fees are charged per visit and depend on the length and type of appointment. The initial evaluation is longer than a follow-up and is priced accordingly. Work performed outside a visit — extended record review, letters, forms, coordination with other clinicians — is generally billed separately, because it is not covered by the visit fee.
[List every fee you charge with the session length attached to each: initial evaluation, standard follow-up, extended follow-up, brief phone or portal consultation, records review, letters and forms, and any retainer or concierge fee. The federal No Surprises Act and California billing-transparency rules mean the Good Faith Estimate you hand a self-pay patient must match these numbers exactly, so publish the real ones and revise this page whenever they change. If the full table belongs on /fees.html, put it there and link to it — but do not leave a prospective patient unable to find a number anywhere on the site.]
See Fees & access for the full schedule.
What is a superbill?
A superbill is an itemised receipt for a visit you have already paid for. It contains everything an insurer needs to process an out-of-network claim: your name and date of birth, the date and place of service, the CPT procedure code for the visit, the ICD-10 diagnosis code, the fee charged, the amount you paid, and the clinician's name, NPI and tax identification number.
You submit it to your insurer yourself, usually through the plan's member portal or app. The insurer applies your out-of-network deductible and then reimburses you directly, at whatever rate your plan allows — typically a percentage of the plan's allowed amount rather than a percentage of what you actually paid, which is why reimbursement often lands below what patients expect.
Two caveats are worth knowing in advance. A superbill is not a guarantee of payment; reimbursement depends entirely on your plan's out-of-network benefit, and some plans have none. And because a superbill carries a diagnosis code, submitting it discloses your psychiatric diagnosis to your insurer — a trade-off some patients decide is not worth the money.
What is a Good Faith Estimate?
Under the federal No Surprises Act, in effect since 1 January 2022, any patient who is uninsured — or who is insured but does not intend to submit the visit to insurance — is entitled to a written Good Faith Estimate of expected charges before care begins. It is your right, not a courtesy.
The timing is specified. The estimate must be issued automatically when a service is scheduled: at least three business days ahead if the appointment is booked ten or more business days out, and at least one business day ahead if it is booked three to nine business days out. It must also be provided within three business days of any request, whether or not you have scheduled anything.
For ongoing care such as medication management, the estimate covers a stated number of visits over a period of up to twelve months, and is reissued when the plan of care changes. If the bill you ultimately receive exceeds the estimate by $400 or more, you may contest it through the federal patient–provider dispute resolution process; the notice explaining how is included with the estimate.
A Good Faith Estimate is an estimate, not a contract, and it does not include charges billed by anyone else — a laboratory, a pharmacy, or another clinician you are referred to. Ask for yours before the first visit rather than after it.
What is your cancellation policy?
An appointment reserves a specific block of time that cannot realistically be filled at short notice, so most private practices ask for advance notice and charge for late cancellations and missed visits. Because no clinical service was delivered, there is nothing to bill or to put on a superbill, and health plans generally do not reimburse these charges — so expect one to be your own cost.
[State your notice window (24, 48 or 72 hours), the amount charged for a late cancellation and for a no-show, whether the full session fee applies, and how you handle genuine illness or emergency. This charge must also appear in your written treatment consent and in the Good Faith Estimate, not only on this page — a fee disclosed nowhere but a website is difficult to defend if it is ever disputed.]
Medication, therapy and neuromodulation
What each treatment actually is, what the evidence does and does not support, and where the line falls between clinical care and research.
What is your philosophy on medication?
Careful medication management tends to share a few features regardless of who is doing it. A target is named before a drug is started, so that both people know what is being treated and what improvement would look like. Doses are changed one at a time, so that an effect can be attributed. Response is measured with the same instrument at each visit rather than recalled. Trials are given long enough to count — usually six to eight weeks at an adequate dose — and then stopped if they have not worked, rather than accumulated. And deprescribing is treated as a legitimate clinical goal rather than a failure.
[Write two or three sentences in your own voice about how you actually approach medication: when you start one, when you deliberately hold off, how you decide something is not working, what you do about polypharmacy you inherit, and how you handle tapering. This is the answer prospective patients read most closely, and it is the one paragraph on this site that cannot be drafted for you without putting words in your mouth.]
Do you prescribe controlled substances or stimulants?
Stimulants, benzodiazepines and similar medications carry legal requirements that shape how they can be prescribed, and it is worth knowing them before you ask. Schedule II drugs, which include most stimulants, cannot be refilled — a new prescription is required for each fill, although a prescriber may issue up to three sequential prescriptions covering ninety days with earliest-fill dates. California requires prescriptions to be transmitted electronically, and requires the prescriber to check the CURES prescription drug monitoring database before first prescribing a Schedule II, III or IV medication to a patient and at least every four months while that treatment continues. Federal rules on prescribing controlled substances by telemedicine have been repeatedly extended and revised since 2020 and remain in flux; whatever rule is in force at the time applies.
These requirements are not obstacles so much as the reason such prescribing is slower and more structured than other prescribing, and why a practice's policy on it is usually stated in advance.
[State your policy directly: whether you prescribe stimulants, benzodiazepines and other controlled substances at all; whether you will continue a prescription started by another clinician; whether an in-person visit is required before or during controlled-substance treatment; whether you require a treatment agreement, urine drug screening, or documentation of a prior diagnostic evaluation for ADHD; and how frequently a patient must be seen for that prescribing to continue. Vagueness here reliably attracts the referrals you least want.]
Do you offer psychotherapy?
Psychiatrists differ in this. Some provide psychotherapy themselves, in weekly sessions of forty-five minutes or more. Others provide diagnostic evaluation and medication management and work alongside a separate psychotherapist, with the two clinicians in contact. Both are legitimate models, but they are different experiences and different costs, and patients are often surprised at the first visit to learn which one they have booked.
In major depression, and in several anxiety disorders, the evidence generally favours combining medication with an evidence-based psychotherapy over either alone. That finding does not extend evenly across every diagnosis, so whether therapy belongs in your plan is a question about your situation rather than a rule — but where it does belong, the practical question is usually how it is arranged rather than whether to have it.
[Say whether you provide psychotherapy yourself, in which modality and at what session length, or whether you provide medication management and collaborate with a separate therapist. If the latter, say whether you expect patients to already have one, whether you will help them find one, and how you handle communication between you. Patients routinely assume a psychiatrist provides therapy; correcting that assumption here is far better than correcting it in the room.]
What is pharmacogenomic testing, and does it help?
Pharmacogenomic testing analyses a cheek swab or blood sample for variants in genes that affect how the body handles medication — most relevantly the liver enzymes CYP2D6 and CYP2C19, which metabolise many antidepressants and antipsychotics.
The evidence is real, but narrower than the marketing suggests. Where it is strongest it is pharmacokinetic: a CYP2C19 poor metaboliser reaches higher blood levels of escitalopram or citalopram at a standard dose, and published dosing guidance from the Clinical Pharmacogenetics Implementation Consortium exists on that basis. A small number of tests genuinely predict serious harm — HLA-B*15:02 screening before carbamazepine in patients of Southeast Asian ancestry is the clearest example in this field.
Where the evidence is weakest is exactly where the commercial panels make their claims. Reports that sort several dozen drugs into green, yellow and red columns rest on proprietary combinatorial algorithms rather than on validated biology, and the large randomised trials of those panels have shown that testing changes prescribing more reliably than it changes outcomes: differences in remission have been small, inconsistent, or not sustained. No available test predicts which medication will work for a given person.
A fair summary: testing is worth considering when there has been unusual sensitivity, severe side effects at low doses, or repeated non-response, and it is best read as one input into a decision rather than as the decision. Insurance coverage is inconsistent and out-of-pocket costs vary widely, so confirm the price before a sample is sent.
What is TMS?
Transcranial magnetic stimulation uses a coil held against the scalp to deliver brief, focused magnetic pulses that induce a small electrical current in the cortex directly beneath it — most often the left dorsolateral prefrontal cortex when the target is depression. It is non-invasive, requires no anaesthesia and no sedation, and the patient is awake and can drive home afterwards.
TMS has been cleared by the FDA for treatment-resistant major depressive disorder since 2008, and subsequently for obsessive-compulsive disorder, smoking cessation, and as an adjunct in anxious depression. A conventional course is a daily session on weekdays over roughly six weeks; accelerated protocols compress a comparable number of pulses into a few days, and one such protocol using individualised functional-connectivity targeting has also received clearance. The most common side effects are scalp discomfort and headache during the first sessions; the serious risk is seizure, which is rare and is screened for.
Targeting is where the field is currently moving. Rather than measuring a fixed distance from the motor cortex, individualised approaches use each person's own functional MRI connectivity to place the coil, on the reasoning that the relevant target is defined by its connections rather than by an average anatomical landmark. That is the subject of ongoing research, including a Stanford study of connectivity-guided TMS for chronic tinnitus in which Dr. Pellionisz is involved — see Research & Trials.
[State plainly whether TMS is something a patient can receive through this practice, whether you evaluate patients and refer to a specific TMS centre, or whether your TMS involvement is research only. Your published TMS work sits inside a research protocol, and a reader who assumes it is a clinical service available here is precisely the misunderstanding this page exists to prevent.]
What is focused ultrasound, and is it available?
Low-intensity focused ultrasound (LIFU) uses acoustic energy shaped and steered through the intact skull to converge on a small volume of tissue and alter its activity. Its practical appeal in psychiatry is depth and precision: it can reach structures such as the amygdala, the subgenual cingulate or the thalamus, which lie well beyond what a magnetic coil on the scalp can influence directly.
It should not be confused with high-intensity MR-guided focused ultrasound, which uses far greater energy to create a deliberate thermal lesion and is approved for movement disorders such as essential tremor. LIFU operates at intensities orders of magnitude lower and is intended to be reversible, producing no lesion at all.
In psychiatry, focused ultrasound is investigational. It is not FDA-approved or cleared for any psychiatric indication, and the legitimate route to it is enrolment in a clinical trial. Early studies in treatment-resistant depression are small, generally open-label or with limited sham control, and the field does not yet know the durable effect size, the right dose, or the right target. Any clinic advertising focused ultrasound as an established treatment for a psychiatric condition is ahead of the evidence, and that is worth saying plainly.
Dr. Pellionisz is a sub-investigator on an industry-sponsored LIFU trial for treatment-resistant depression at UCSF (Attune Neuroscience, 2024–present). That is research, conducted under a protocol with its own eligibility criteria and consent process.
[Say explicitly that focused ultrasound is not offered as clinical care here and that the only route to it is trial enrolment, and state whether you are able to direct interested patients toward the UCSF study or others. Decide as well whether you want trial enquiries arriving at all — if you do, name the study coordinator's contact rather than your clinical inbox, because research recruitment and clinical intake must stay separate.]
What is ketamine or esketamine, and do you offer it?
These are two different things and are often conflated.
Esketamine (Spravato) is an intranasal formulation approved by the FDA in 2019 for treatment-resistant depression in adults used together with an oral antidepressant, in 2020 for depressive symptoms in adults with major depression and acute suicidal ideation or behaviour, and more recently as a monotherapy for treatment-resistant depression. Because of the risks of sedation, dissociation and misuse, it is available only under a Risk Evaluation and Mitigation Strategy (REMS): it may be dispensed and self-administered only in a certified healthcare setting, the patient must be monitored on site by a healthcare professional for at least two hours after each dose, the patient cannot drive for the rest of that day, and both the treating setting and the pharmacy must be enrolled in the REMS programme. It is a covered benefit under many insurance plans, though prior authorisation is usual.
Racemic ketamine given intravenously is a different situation. It is not FDA-approved for depression and is used off-label. The evidence for a rapid but transient antidepressant effect after a single infusion is reasonably strong; the evidence about maintenance dosing, effect durability, long-term cognitive safety and abuse liability is much thinner. Off-label infusions are rarely covered by insurance and are not subject to REMS oversight, which is one reason the quality and safety practices of ketamine clinics vary widely. Compounded oral or sublingual ketamine sold through telehealth companies has drawn specific FDA warnings about unsupervised use.
Neither is a first-line treatment, and both are considered after adequate trials of established options rather than instead of them.
[State whether you prescribe or administer esketamine or ketamine, refer out for it, or neither. Spravato can only be given in a REMS-certified setting with on-site monitoring, so if you are not certified, say so and name where you refer. If you do refer, note what you expect of a receiving clinic — a psychiatrist on site, real monitoring, and a stated plan for what happens after the acute series — since patients cannot easily judge that themselves.]
Refills, messages, forms and privacy
The day-to-day mechanics of being a patient here — including what to do when something cannot wait.
How do I request a refill?
The fastest route is almost always through the pharmacy, which sends an electronic request to the prescriber directly; asking the pharmacy first avoids a duplicate prescription and the confusion that follows. Request refills several business days before you run out rather than on the day, and be aware that prescriptions are written to last until the next planned visit, so a lapsed follow-up is the usual reason a refill stalls.
Controlled substances are handled differently by law and cannot be refilled by phone message or portal note; each fill requires a new prescription.
[Give the exact mechanism you want used (pharmacy-initiated request, portal message, or phone), the turnaround you are willing to commit to in business days, and the rule that ties refills to being seen — for example, no refills issued more than X weeks past the last visit. Make this consistent with the visit-frequency answer under Getting started. Patients run out on Friday evenings; a specific written rule prevents most of those calls.]
How do I reach you between visits?
Between-visit contact is for things that can wait for a reply during business hours: a new side effect, a scheduling change, a refill that has not arrived, a question about a dose. It is not a channel for urgent safety concerns, and it should not be used for anything time-critical — see the emergency answer below.
[Name the single channel you actually monitor (patient portal, practice phone line, or practice email), say who reads it, and give a realistic response time in business hours — then hold to it, because a stated response time you miss is worse than none. Say what belongs there and what does not. Also state whether calls or messages beyond a certain length or complexity are billed, and at what rate, so that a charge for between-visit work is never a surprise.]
Please do not send confidential health information by ordinary email or through the website form; neither is secure.
What if I have an emergency?
This practice does not provide emergency or after-hours crisis coverage. Messages sent to the practice are not monitored continuously and must never be used to report an urgent safety concern.
If you are in danger now, or worried that you might be:
- Call or text 988 — the Suicide & Crisis Lifeline. Free, confidential, 24 hours a day. Press 1 for the Veterans Crisis Line, press 2 for Spanish, or chat at 988lifeline.org.
- Call 911, or go to your nearest emergency department, if there is an immediate threat to life, an overdose or ingestion, or you cannot keep yourself safe until help arrives.
- Text HOME to 741741 to reach the Crisis Text Line.
Calling 988 also connects you to local county crisis services, which in many areas can send a mobile crisis team rather than police. You can call 988 about someone else, not only about yourself.
If you are already in an emergency department and the clinicians there want records or collateral history, ask them to contact the practice during business hours. Care in an emergency should never wait on that call.
Do you complete disability, FMLA or school forms?
Paperwork of this kind — short-term or long-term disability, FMLA certification, workplace accommodations under the ADA, academic accommodations or a leave of absence — requires reviewing the record, writing a substantiated opinion, and often corresponding with a third-party administrator afterwards. It is real clinical work performed outside a visit, and most practices charge for it and give a turnaround time.
One limit applies everywhere and is worth stating plainly: a physician can only attest to what they have personally assessed, over the period they have assessed it. Retrospective certification of a period before treatment began, or an opinion about a functional impairment that has not been evaluated, is not something any careful clinician will sign.
[State which forms you will complete — disability, FMLA, ADA or academic accommodations, leave of absence, jury duty, emotional support animal letters — and which you will not. Give the fee, the turnaround time, and whether you require an established treatment relationship of some minimum duration first. If you decline ESA letters or retrospective disability certification, saying so here is far easier than saying it for the first time in the room.]
How is my privacy protected?
Psychiatric records receive protection under HIPAA and, in California, under the Confidentiality of Medical Information Act, which is in several respects stricter. Nothing from your record is released to an employer, a school, a family member or another clinician without your written authorisation, and that authorisation is specific and revocable rather than blanket. Psychotherapy notes, when they are kept separately from the rest of the record, carry additional protection and are not included in a general records release.
The exceptions are narrow, defined by law rather than by practice preference, and you should know them before you begin: a serious and imminent threat of violence toward an identifiable person; suspected abuse or neglect of a child, elder or dependent adult, which California law requires be reported; a person so impaired by mental illness that they cannot provide for their own basic safety; and a valid court order. A subpoena alone is not a court order and is generally resisted.
Practically: ordinary email and text messages are not secure and should not carry clinical detail. If you use insurance, submitting a claim or a superbill necessarily discloses a diagnosis to your insurer.
[Name the electronic health record, patient portal and telehealth platform you use, and confirm a signed business associate agreement is in place with each vendor. Then confirm whether you transmit any claims or eligibility checks electronically, since that is what determines whether you are a HIPAA covered entity rather than a physician voluntarily holding to the same standard — the distinction changes what your Notice of Privacy Practices must say. The notice at /legal/hipaa.html should name the same systems.]
See the HIPAA Notice of Privacy Practices and the website privacy policy.
Still have a question?
If something here is unclear, or your situation does not fit any of these answers, write and ask. General questions about how the practice works are welcome — please keep clinical detail out of email and save it for the visit.