New Patient InquiryPlease complete the form below and a team member will be in contact with you within 48 business hours. Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * How do you prefer to be contacted? * Phone Email What services are you interested in? Medication Management Psychotherapy Medication Management & Psychotherapy Are you comfortable with telehealth? Yes No Reason for seeking services: Current Diagnoses: * If you do not have any current diagnoses, please enter N/A. Current Medications: * If you currently do not have any medications, please enter N/A. Current mental health medication provider and reason for changing: * If you currently do not have a provider, please enter N/A. Current insurance provider: * Any further information you feel would be helpful for the providers to know: Thank you, we will be contacting you soon!
