Request for Mental Health Services
Our clinicians are ready to see you at Atracare!

We are currently accepting new patients for medication management and talk-therapy. 

By filling out this form below, you're letting us know that you'd like to be contacted about mental health services.  If you are a parent/guardian, please fill out your child's information in the space below.

Our Mental Health Treatment Coordinator will contact you within two business days (Monday through Friday).

Please note, since we are a specialty service, we require a referral order from your primary care physician's office before you have your initial mental health appointment. 

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Full Legal Name *
Parent/Guardian Name (If Applicable)
Gender
Date of Birth *
MM
/
DD
/
YYYY
Phone (xxx-xxx-xxxx) *
Email *
Type of Insurance *
Since therapy is a specialized service, we require referrals for services. Will you be able to get a referral from your primary doctor?

If you answer no, we may not be able to provide you with immediate care. 
 *
Name of Primary Care Physician?
If applicable, please list all current medications.   *
Are you interested in therapy, medication management, or both? *
Gender Preference for Therapist *
Therapy Location Preference *
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