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

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

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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