Medication Management with Holistic Healing Partners Waitlist

Thank you for reaching out to see one of our nurse practitioners! Unfortunately, at this time we are closed to new clients. 

Please answer these questions to help us ensure we are a good fit for your needs. 

When we reopen to new clients, you will be contacted via text message and/or phone call to discuss next steps with getting started with Holistic Healing Partners

Thank you!

Holistic Healing Partners, LLC
Courtney Holmes, APRN
Diana Greenia, APRN
Reisa Miller, Assistant
Sign in to Google to save your progress. Learn more
Email *
Are you looking to sign up for Anxiety Reduction Group therapy with acupuncture?
Clear selection
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) *
Required
How did you find us? *
Required
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? *
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.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Holistic Healing Partners, LLC. Report Abuse
Google Forms