This form is provided as a way to make the process of getting accepted into the practice more simple and efficient, but it can only be used if you agree that providing this information does not mean any doctor/therapist-patient/client relationship is being formed, and that no guarantee is provided that you will indeed be accepted into the practice. 

If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter, do not use this service. Instead, call 911 or go to your closest emergency room.