Appointment Request Form

The information provided will help us to best serve you. Someone from our office will be in touch once you submit this form if you are a candidate for our waiting list which we are trying our best to work through. Thank you so much!

PLEASE NOTE WE ARE NOT IN-NETWORK WITH ANY MEDICARE, MEDICAID, TRICARE, OR MEDCOST PLANS AT THIS TIME AND UNABLE TO ACCEPT THOSE INSURANCES.

FUNCTIONAL MEDICINE SERVICES ARE SELF-PAY ONLY. THANK YOU!

Name*

First NameLast Name

Date of Birth *

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Mental Health Medication ManagementRecovery (Suboxone etc.)Functional / Holistic Mental Health (geared towards finding root causes)Diagnosis (Psychiatric Evaluation)Advanced Blood Work Testing to Detect Underlying Issues Contributing to Mental Health ConditionsTherapy

Benzodiazepines (Ativan, Klonopin, Xanax, Valium)Stimulants (Adderall, Vyvanse, Concerta, Ritalin, Focalin, Azstarys, etc.)Buprenorphine (Suboxone, Subutex)OTHERNO

Please list all your current medications and dosages: *

CHANGECONTINUEN/A NOT TAKING ANY MEDICATION

Please list what symptoms you are currently experiencing and seeking help with: *

Do you have insurance, if so please list with whom?*