Services

Beyond symptom management

Careful diagnosis, deliberate medication decisions, and follow-up that is actually measured — for people whose psychiatric care has so far been a sequence of trials without a formulation.

Most people who come to a practice like this one have already been treated. They arrive with a list of medications tried, a diagnosis that has changed two or three times, and no clear account of why any of it was chosen. The problem is rarely a lack of effort. It is that ordinary psychiatric visits are short, the history is reconstructed in fragments, and response is judged by recollection rather than by anything written down.

The work here starts from the opposite end. The first task is a formulation: what is actually driving the presentation, what has genuinely been tried at an adequate dose and duration, and what has never been tested at all. Only then does treatment selection become a reasoned decision rather than a guess. From there, response is tracked with the same instruments at the same intervals, so that a change in the plan follows from data rather than from the tone of a single appointment.

The services below describe how that is organised in practice. They are not separate products; care often moves between them. Nothing on this page is a promise of outcome. Psychiatry has real limits, and the honest version of precision is knowing which decisions the evidence can inform and which it cannot.

Scope of practice

What this practice provides

Nine areas of clinical work, described plainly.

Comprehensive Diagnostic Evaluation

Care begins with an extended initial consultation rather than a brief intake. The purpose is to build a longitudinal history — developmental, medical, psychiatric, substance, family, and treatment history reconstructed in order, with attention to what each prior medication actually did, at what dose, and for how long. Where it will change the formulation, and with your written permission, collateral information is sought from a partner, a family member, or a prior treating clinician. Standardised symptom measures are administered at the outset so that later visits have a real baseline to compare against, and records from previous psychiatrists, therapists, and hospitalisations are reviewed before the first appointment where possible.

[State the length and fee of the initial evaluation, and whether it is scheduled as one appointment or split across two. This must match what you actually charge: the federal No Surprises Act and California AB 1020 require a written Good Faith Estimate for self-pay patients before the visit, and the figure on this page is the one patients will hold you to.]

Precision Medication Management

Medication decisions are made explicitly and explained. That includes rational combination treatment where the evidence supports it — and, just as often, deprescribing: stopping agents that were added during a crisis, never reassessed, and are now contributing side effects without benefit. Dose, duration, and target symptoms are defined in advance so that a trial can be called adequate or inadequate rather than left ambiguous. Pharmacogenomic testing is used selectively, in the specific situations where a result would change a decision — for example, unusual sensitivity to standard doses, or a history of poorly tolerated trials across several agents. It is worth being clear about its limits: current panels mostly describe how quickly you metabolise a drug, not whether it will work for you, and no available test predicts response to an antidepressant. Where a result would not alter the plan, testing is not ordered.

[Say whether you order pharmacogenomic testing through the practice or send patients elsewhere, name the laboratory if you have a preferred one, and state the out-of-pocket cost and whether insurance is billed. Patients are frequently marketed these panels directly and will ask; an explicit position here prevents a surprise bill and an awkward first visit.]

Treatment-Resistant Depression

Depression that has not responded to two or more adequate medication trials is a different clinical problem from depression at first presentation, and it is approached differently. The first step is verification: many apparent non-responses turn out to be undertreated trials, unrecognised bipolarity, untreated sleep apnoea, thyroid or iron abnormalities, ongoing alcohol use, or a diagnosis that was never quite right. Where resistance is genuine, the discussion turns to sequencing — which augmentation strategies have the strongest evidence for your particular presentation, in what order, and what would count as a fair test of each. Interventional options belong in that conversation early rather than as a last resort, and the point at which they should be considered is discussed openly, including what the evidence does and does not support for each.

[Confirm how you want this framed: do you accept patients whose primary request is a referral for an interventional treatment delivered elsewhere, and will you provide ongoing medication management during someone else's TMS, ECT, or esketamine course? Referring clinicians read this section to decide what to send you, so the answer shapes your referral base.]

Neuropsychiatric Presentations

Some psychiatric symptoms arise in the setting of neurological illness, and they respond poorly to treatment that ignores the neurology. This includes mood, apathy, irritability, and cognitive change in the context of epilepsy, movement disorders, multiple sclerosis, stroke, and dementia; persistent cognitive, mood, and sleep symptoms after concussion or more severe head injury; and functional neurological symptoms, which are common, are diagnosed on positive clinical signs rather than by exclusion, and are treatable. The work often involves separating what is attributable to the neurological condition, what is attributable to its treatment, and what is an independent psychiatric illness that deserves treatment in its own right. Close coordination with neurology is usually essential, and evaluation may include referral for formal neuropsychological testing where the cognitive picture is unclear.

[Specify what you require before accepting a neuropsychiatric referral — an existing neurologist, prior imaging, a completed neuropsychological battery — and whether you order neuroimaging or neuropsychological testing yourself or refer for it. Patients with post-concussive and functional symptoms are often bounced between specialties, and vagueness here produces inappropriate referrals.]

Interventional & Neuromodulation Consultation

Consultation on candidacy for interventional treatments — transcranial magnetic stimulation, electroconvulsive therapy, ketamine and esketamine, and low-intensity focused ultrasound — for people who want a considered opinion on whether any of them fit their situation. A candidacy assessment covers diagnosis and whether it is the right indication, prior trial adequacy, medical and seizure risk, contraindications, what the evidence base actually shows for the specific modality and indication, the practical burden of each course, and what maintenance would involve afterwards. Some of these treatments have substantial evidence in specific indications; others remain investigational, and focused ultrasound for depression is at present a research modality rather than an established clinical treatment. Saying so plainly is part of the consultation.

[This placeholder is the most important one on the page. State, treatment by treatment, which of TMS, ECT, ketamine/esketamine, and focused ultrasound are (a) delivered by you in this practice, (b) not delivered here and referred to a named centre, or (c) available only to participants in a research protocol. Your focused ultrasound, fMRI-guided TMS, and kTMP work is documented as research, and a page that lets a reader infer they can receive it as clinical care creates both a licensing exposure and a consent problem. If a treatment is research-only, say so in that sentence and link to /research.html.]

Second-Opinion Consultation

A one-time consultation for diagnostic clarification, requested either by a patient or by a treating clinician who wants another view. This is a bounded piece of work rather than a transfer of care: the history and records are reviewed in depth, the diagnosis is reconsidered from first principles, and the treatment sequence to date is assessed for whether each trial was genuinely adequate. The product is a written formulation and a set of specific, prioritised recommendations sent back to the referring clinician, who remains responsible for ongoing treatment. It is often most useful when a case has stalled, when the diagnosis has shifted repeatedly, or when a significant decision — an interventional referral, a long-term medication commitment, a diagnosis with occupational consequences — deserves a second reading before it is made.

[State the fee for a second-opinion consultation, how long the written formulation takes to reach the referring clinician, and whether you are willing to assume ongoing care afterwards if the patient asks. Referring clinicians will not send cases without knowing whether the referral is a loan or a transfer.]

Collaborative Care with Existing Treaters

Many people arrive with a therapist they trust and no wish to change. In that situation this practice provides the psychiatric half of the care — diagnosis, medication, and medical decision-making — while the therapy continues where it is. With your written consent, that means real communication rather than parallel silence: a shared understanding of the formulation, agreement on what each of us is treating, and direct contact when the picture changes or a decision affects both halves of the plan. The same arrangement works alongside a primary care physician, a neurologist, or a treatment team managing a medical condition that interacts with psychiatric treatment. Splitting care this way works well when the communication is deliberate and poorly when it is not, so it is set up explicitly at the start.

[Note whether you require patients to be in concurrent psychotherapy for certain presentations, and how you want therapists to reach you for clinical coordination — a practice line, a secure message route, or scheduled contact. Do not list referral partners here unless you have their agreement to be named.]

Psychotherapy-Informed Medication Visits

Medication visits here are scheduled at [State the scheduled length of a standard follow-up visit, in minutes, and drop this placeholder into the sentence in place of it. It must match the standard follow-up row of the fees table exactly — patients read the two pages together, and a visit length published here is one they will expect to receive.] and are conducted psychotherapeutically — meaning the visit attends to how you understand your illness, what the medication means to you, the patterns that recur in your relationships and work, and the ambivalence that shapes whether a treatment is actually taken. That context usually improves the medication decision itself, because non-response and non-adherence are frequently the same conversation. It should be said clearly what this is not: it is not a course of formal psychotherapy, it does not follow a structured protocol such as CBT or a manualised trauma treatment, and it does not replace working with a therapist for people who need one. Where formal therapy is indicated, the recommendation will be to arrange it.

[State whether you offer standalone psychotherapy in this practice — and if so, which modalities, at what session length and frequency, and at what fee. If you do not, say so in one sentence, because patients read "psychotherapy-informed" as an offer of therapy and will book on that assumption.]

Measurement-Based Care

This is the practice's organising commitment. The same validated symptom scales are administered at defined intervals rather than occasionally, so that response, partial response, and non-response are distinguishable, and so that a decision to change treatment rests on a trajectory rather than on how a particular day happened to go. Where it is useful and you are willing, objective data can be brought in as well — sleep and activity records from a device you already wear can make an otherwise invisible pattern legible, particularly in bipolar spectrum illness and in depression with prominent sleep disturbance. Reasoning about brain circuits informs how symptoms are grouped and how treatments are chosen, drawing on what the imaging literature has established about the networks involved in mood and anxiety disorders. The limit must be stated plainly: no brain imaging test, blood test, or genetic panel is diagnostic for any psychiatric condition today. A clinical scan is ordered to rule out neurological disease, not to confirm a psychiatric diagnosis, and any practice that offers imaging as diagnostic is selling something the field cannot yet support.

[List the instruments you actually administer and at what interval (e.g. which depression, anxiety, and functional measures, at every visit or monthly), and state how patients complete them — in the portal, by secure link, or in the office. If you accept wearable or sleep data, name the specific route by which it reaches you, since a patient emailing an export is a HIPAA problem rather than a workflow.]

Referral guide

Conditions this practice is set up to see

An indicative list rather than an exhaustive one. If your situation is not described here, it is reasonable to ask.

[Go through the six lists below and confirm or cut each condition individually before publication. This is a scope-of-practice representation: a patient reads any named diagnosis as "treated here", and a board or payer reads the list the same way. Delete anything you would decline or refer out — peripartum and perimenopausal mood change, body dysmorphic disorder, prolonged grief disorder, functional neurological symptom disorder, post-stroke apathy and the circadian entries are the ones most likely to need cutting — and add anything you do see that is missing. Once you have a real caseload, this heading can go back to describing it.]

Mood disorders

Major depressive disorder, including recurrent and treatment-resistant presentations
Persistent depressive disorder
Bipolar I and II disorder, including diagnostic clarification after an unclear course
Depression with prominent anhedonia or cognitive symptoms
Peripartum and perimenopausal mood change

Anxiety and OCD

Generalised anxiety disorder
Panic disorder and agoraphobia
Social anxiety disorder
Obsessive-compulsive disorder
Body dysmorphic disorder and related conditions
Health anxiety, particularly following a medical illness

Trauma-related conditions

Post-traumatic stress disorder
Trauma-related symptoms following medical illness, injury, or intensive care
Complicated grief and prolonged grief disorder
Adjustment disorders following a major life change

Neuropsychiatric conditions

Mood and behavioural change in epilepsy, Parkinson's disease, and multiple sclerosis
Post-stroke depression and apathy
Persistent post-concussive symptoms
Functional neurological symptom disorder
Neuropsychiatric symptoms in early neurodegenerative illness
Cognitive complaints requiring differentiation from mood disorder

Sleep and circadian problems

Chronic insomnia occurring with a psychiatric condition
Circadian rhythm disruption, including shift-work and delayed-phase patterns
Sleep disturbance driving or sustaining mood symptoms
Nightmares in the context of PTSD

When another setting is a better fit

Some presentations need resources an outpatient private practice cannot provide, and starting in the wrong setting costs time that matters. This practice is generally not the right place for care if you are in an active psychiatric emergency or need urgent stabilisation; if the primary problem is a substance use disorder requiring medically supervised withdrawal or a structured addiction programme; or if the primary problem is an eating disorder requiring medical monitoring, weight restoration, or a higher level of care. In each of those situations the appropriate step is a programme equipped for it, and care here may be reasonable afterwards.

[Confirm or adjust this exclusion list before publication — it is a clinical scope statement about your own practice, not a generic one. Consider whether you also want to exclude primary psychotic disorders requiring intensive coordination, active suicidality needing frequent contact, patients under 18, or presentations requiring court-ordered treatment, and add anything you do accept that a reader might wrongly assume you do not.]

Boundaries of the practice

What this practice does not provide

Stated in advance, because finding out at the wrong moment is worse than knowing now.

Emergency and after-hours crisis care

This practice does not provide emergency or after-hours crisis services, and messages are not monitored continuously. If you are in crisis or thinking about harming yourself, call or text 988 (Suicide & Crisis Lifeline), call 911, or go to your nearest emergency department. Emergency departments and crisis services are staffed around the clock and are the appropriate resource for an acute situation; an outpatient practice is not a substitute for them.

[Describe how urgent but non-emergency matters are handled between visits — the route patients should use, and who covers when you are away. Do not state a response time here unless you are certain you can meet it consistently, because a published turnaround becomes the standard you are measured against.]

Disability, forensic, and administrative evaluations

Evaluations performed for a third party — an insurer, an employer, a court, or an attorney — serve a different purpose than treatment and are governed by different rules about confidentiality and objectivity. Combining the two roles compromises both, so treating clinicians generally do not perform them for their own patients.

[State your position explicitly on each of these, because patients ask about all of them: independent medical and forensic evaluations, disability determinations and ongoing disability paperwork, FMLA and leave certification, fitness- for-duty assessments, emotional support animal letters, academic accommodation letters, and testimony. Say which you will complete for established patients as part of treatment, which you decline entirely, and whether any carry a separate fee.]

Controlled substances

Controlled medications — stimulants, benzodiazepines, and others — are prescribed only where they are clinically indicated, only after an adequate evaluation, and only within a defined plan that includes how the treatment will be monitored and reviewed. A request for a specific controlled medication is not itself a reason to prescribe it, and this practice is not a setting for continuing a regimen that has not been reassessed.

[Write your actual controlled-substance policy here — it is the single most common source of first-visit conflict. Address: whether you initiate stimulant treatment and what evaluation you require first; whether you will continue a benzodiazepine or stimulant regimen started elsewhere, and on what terms; your position on tapering; refill timing and the fact that you check the CURES database as California law requires; whether in-person visits are required for controlled prescribing under the telehealth rules in force when you publish; and what happens if the agreement is not kept.]

Start with a conversation

If you are unsure whether this practice fits your situation, a brief exchange before booking is usually the fastest way to find out — including a referral elsewhere if that is the better answer.

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