Due to COVID-19, we are now offering Telemed appointments for new patient evaluations.

Thank you for your interest in scheduling a new patient appointment with our practice. To schedule your appointment as soon as possible, we request that all new patients submit a brief inquiry online. *If you are in crisis and need immediate care, please call 911 or go to your nearest emergency room.

Patient name

Email

Date of Birth

Sex
MaleFemale

Phone Number

Address

Who were you referred to?

Who referred you to our practice?

Please provide a brief description as to the reason for your visit

Insurance

Subscriber ID Number (please include alpha pre-fix, if applicable.) If self-pay, please type "none"

Group Number (please write N/A if it does not apply)

Any past psychiatric hospitalizations?
YesNo

Are you seeking FMLA? Please note that our providers require clients to be established for a minimum of six months prior to filling out FMLA.

Are you seeking Short-Term Disability paperwork? It is important to note that we do not fill out short-term disability paperwork.

Any history of alcohol or opioid dependence?

Current or Recent Psychiatric Medications (please include mg & directions)

Appointment Preference (Please indicate Telemed or in-person):

Time Preference:
MorningAfternoonNoPreference