Contact Us Form

Contact Us Form
What Do You Need Assistance With?*
Are you an outside provider?*

YesNo
Please select an option*
Other
Please select an option *
Billing
Please select an option *
Patient Concern
For the fastest response, please access the medical request form on the Patient Portal

Alternatively, please fill out the form below.
Have you checked our FAQ page?

You can find common billing questions and answers on our FAQ page.
Would you like to schedule online?

Scheduling an appointment is easy. You can use our online appointment booking system to request an appointment at any time.
Name of Organization/Provider*

OrganizationProvider Name
Name*

First NameLast Name
Relationship to patient*
If other than patient, do you have a signed Release of Information?*

YesNo
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Fax
Location*
Medication Requested *
Dose*
Has the medication been canceled at your current pharmacy?*

YesNo
Transfer Location (if applicable)
Updated Name on Insurance Card

First NameLast Name
Updated Legal Name/ Name used for Insurance Purposes

First NameLast Name
Updated Name that you go by

First NameLast Name
Updated Pronouns Used
Updated Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Updated Phone Number
Please enter a valid phone number.
Updated Email
example@example.com
Upload Updated ID

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Do you have questions for a specific provider?*

YesNo
Provider Name*
What is the date/time of the appointment needing to be canceled or rescheduled? *
Would you like a call back to assist with rescheduling your appointment?*

YesNo
Date of Next Follow-up Appointment *

MonthDayYear
Date
Type of paperwork being requested*
When was the paperwork received? *

MonthDayYear
Date
Name of Medication:*
Listed Side Effects*
Preferred method of contact*

PhoneEmailBoth
Best date/time to contact you*
Insurance Name*
Subscriber ID*
Group Plan # *
Effective Date *
Responsible Party*
Please upload a picture of the front and back of the card *

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Will these medical records be released to a third-party (someone other than yourself)?*

YesNo
A representative from our Medical Records Department will email you a link to complete a Release of Information to complete your request.
Payments can be made through our Patient Portal

Alternatively, please fill out the form below.
Type of Service Needed*

Adult TherapyAdult PsychiatryChild & Adolescent TherapyChild & Adolescent PsychiatryCouples CounselingFamily TherapyPsychological TestingGroup TherapyTMS
Appointment Preference*
Comment/Message*
Upload Signed Release of Information

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Please verify that you are human*
Should be Empty:

Contact Us Form

For the fastest response, please access the medical request form on the Patient Portal

Have you checked our FAQ page?

Would you like to schedule online?

Payments can be made through our Patient Portal