Telehealth Appointment Request Form
PLEASE NOTE: This form is only for appointments with providers listed in our Acacia Telehealth Platform. For services with providers at other offices, please complete that particular location's appointment form.

Acacia is an outpatient mental health clinic. We provide weekly individual therapy, couples therapy, group therapy, and medication management services to address a variety of mental health needs. Acacia does not specialize in the treatment of chronic substance abuse and addiction or active psychosis.

If you are an immediate danger to yourself or someone else or are otherwise experiencing a mental health emergency, please call 911 or go to the nearest emergency room.

Depending on the time of year, Acacia may have a waitlist and therefore may be unable to guarantee an initial appointment right away.

*This form is encrypted to ensure the privacy of your information. Acacia has a business associate agreement with Google that ensures your responses are stored within HIPAA guidelines.
Any and all information disclosed on this form is confidential and will not be shared, sold, or distributed to any third parties with the exception of Insurance companies for billing purposes. Thank you.
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