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Appointment Request Form

First Name

Last Name

Phone Number

Patient Birthdate

Pronouns

If family or a friend referred you, what is their name?

If a therapist or another provider provider referred you, what is their name?

Service(s) Requested

Medication Management/Psychiatry

ADHD Assessment

Psychotherapy/Talk Therapy

Briefly describe any mental health or substance abuse concerns

Please list any medical conditions and significant past medical history below, such as Diabetes, Asthma, Hypertension, etc.

Current Medications or Supplements and Doses (if not on medication, write none)

What health insurance do you have? (Note: we do NOT accept Medcaid plans)

The submission of this form does not establish a provider-client relationship. After review, our office will call you with the available appointment times or to discuss further. Due to the volume of requests please allow 2-3 business days to receive a response. Please check the box below to acknowledge the statement. Thank you!