Screening Form and Contact - Rhiana Roque, M.D.

Full Name

Phone Number

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Are you currently in a crisis that requires urgent or emergency mental health services? (e.g., suicidal thoughts, urges to harm self, thoughts of harming someone else)

Yes - do not proceed. Please call or text 911, or go to the nearest emergency department No

Are you a current resident of California or Nevada, USA?

Yes No - do not proceed (Dr. Roque's medical license only allows her to treat patients who are currently in California or Nevada)

Are you specifically looking for ONLY psychotherapy ("talk therapy") from this clinic?

Yes - do not proceed (currently, the clinic does not do therapy only) No

What type of psychiatric services are you seeking?

General Psychiatry Sports Psychiatry (Elite Sport Mental Health clinic) - athletes, coaches, high performance individuals Not sure (you can also visit our websites elitesportmentalhealth.com and rhianaroquemd.com for more information)

Briefly state your interest in the clinic and how we may best assist you.

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Basic Contact Form

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Just want to inquire or send a message?Click below.

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