Message Form for Current Patients
This is for non-emergency matters only. This form is HIPAA compliant and secure, and can be used as an alternative to email or text messaging (which are not secure).
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Type your message below:
I would like a response before my next session, if possible:
Please Select
Yes
No
If you selected "yes" to the question above, select your preferred method of contact:
Text message
Email
Phone call (this option will delay response times)
By signing below, I acknowledge that this message is not likely to be received immediately, and that while the message I typed above will be transmitted in a secure, HIPAA-compliant way, the response to my message (if requested above) is not guaranteed to be secure or private.
Submit
Should be Empty: