New Patient Interest Form

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If you are interested in becoming a new patient, please fill this out and give our admin team 3-5 business days to get back to you. This form is for general inquiries only and does not collect medical or health information. Please do not include private medical details.

***PLEASE NOTE: AT THIS TIME WE ARE NOT ACCEPTING THERAPY PATIENTS***

First Name *

Last Name *

Phone Number *

Email address *

Date of Birth

YYYY

What services are you interested in? *

Talk Therapy (talk psychotherapy ONLY with no medicine being prescribed) ***PLEASE NOTE: AT THIS TIME WE ARE NOT ACCEPTING THERAPY PATIENTS***

Medication management (psychiatric care with a focus on medications to provide support)

Both (a combination of both that has you meeting with both a therapist and a medication management provider) ***PLEASE NOTE: AT THIS TIME WE ARE NOT ACCEPTING THERAPY PATIENTS***

Required

Preferred Method of Contact *

Phone Call

Text Message

Required

Best time to contact you for phone calls (during office hours of Tu-Fri 9am-5pm) *

8am-10am

10am-1pm

2pm-5pm

How did you hear about us? *

I understand this form is for general inquiries only and should not include medical or urgent health information *

Agree

Required

Submit

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