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Future Patient Information:
Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Primary Language
*
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English
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Payment Method
*
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Insurance
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Insurance Network
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Legal Guardian Information:
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Primary Language
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Mobile Phone Number
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Format: (000) 000-0000.
Email
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Contact Information:
Preferred Name
*
First Name
Mobile Phone Number
*
Format: (000) 000-0000.
Email
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Appointment Information
What is the primary reason for the appointment?
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Preferred Method
*
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In-Person
Telehealth
No Preference
Preferred Clinician
*
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Male
Female
No Preference
Is there history of psychiatric hospitalization?
*
Yes
No
Is there history of psychiatric medication?
*
Yes
No
Is there need for psychiatric medication?
*
Yes
No
Is there need for substance abuse treatment?
*
Yes
No
Is there any or expected litigious case management?
*
Yes
No
Is this the first time seeking psychotherapy treatment?
*
Yes
No
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Scheduling:
Please fill out all days of the week you are available to meet for weekly appointments. Typically, all of our patients attend weekly appointments with our clinicians and selecting as many possible openings will speed up the time to get an appointment. Appointment will only be offered for timeframes noted below.
Availability:
*
Rows
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8am
9am
10am
11am
12am
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
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