Group Signup Form
After completing this short form you will be contacted to get you set up with your group. Please email clinic@modyfihealth.com with any questions.
Patient Name
*
First Name
Last Name
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Location
*
Please Select
Maryland
Virginia
District of Columbia
Other
Which group(s) would you like to join?
*
DBT Skills Group - Age 21+
FOOD Group - Age 18+
Ketamine Group - Age 18+
Other
Are you currently seeing a Modyfi provider?
*
Psychiatric Nurse Practitioner
Nutrition Therapist
Mental Health Therapist
None
Other
Submit
Should be Empty: