Visit Request Form
Thank you for reaching out to see one of our nurse practitioners!
Please answer these questions to help us ensure a good fit for your needs.
We’ll contact you with next steps after you submit your responses.
Holistic Healing Partners, LLC
Courtney Holmes, APRN
Diana Greenia, APRN
Reisa Miller, Assistant
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Are you looking to sign up for Anxiety Reduction Group therapy with acupuncture?
Yes, please do not use this form. Text/Call us at 203-701-6161 or
. When calling, please leave a voicemail to ensure getting contacted.
No, please continue with this form.
Maybe, please continue with this form.
What is your first and last name?
What is your mobile number?
What is the reason you'd like a visit? (Check all that apply)
mental health medication
gender affirming provider necessary
Spanish speaking provider necessary
depressed or feeling down
anxious or worrying
bipolar, hypomania, or mania symptoms
attention or concentration problems
hallucinations (seeing, hearing, or feeling things that are not really there)
psychotherapy (we do not provide, would be a referral)
How did you find us?
Referred by someone
If applicable, who referred you to us?
How will you pay for visits?
If applicable, which health insurance plan do you have?
Are you taking mental health medication?
If applicable, please provide a list of current medications you are taking for mental health.
Are you CURRENTLY in a mental health program?
Intensive Outpatient Program
Substance Abuse Program
Have you been hospitalized for mental health care in the past 6 months?
Will you be located in Connecticut at the time of all visits with us?
Is there anything else you'd like us to know about the reason for your visit?
Do you have a preferred day or time of day for your appointments? For example, Monday afternoons
Thank you for completing our form! Please be sure to hit submit. We will get back to you during usual business hours, Monday through Friday 9am to 5pm. All information submitted through this form is confidential and will only be seen by authorized members of Holistic Healing Partners, LLC.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Holistic Healing Partners, LLC.