Maristan Appointment Request Form

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Assalamu Alaykum,

Thank you for choosing the Maristan clinic for your mental health needs.

If you have any questions, feel free to reach out to our team. We appreciate your patience and understanding.

Please complete this form using your personal information. If you have any questions please email clinic@maristan.org

* Please note that in addition to telehealth sessions, Maristan also conducts in-person sessions by request.

Your Email *

Who are you seeking services for today? *

*Note: Due to state regulations, you may only submit a form for yourself or those whom you have legal guardianship over.

Myself

My child or an individual I have legal guardianship over who is under the age of 18

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