Initial Contact Form

Your Name*

First NameLast Name

Your E-mail*

Phone Number*

Area CodePhone Number

Patient's name (if different from the person filling this form)

First NameLast Name

Patient's Date of birth(if different from the person filling this form)

Brief Description of why you have called this mental health care office *

Confidentiality and Disclaimer

Thank you for your interest in our services. We are committed to protecting your privacy and maintaining the confidentiality of your information. Please note that this platform is HIPAA compliant, ensuring that all your personal and health information is kept confidential.

By completing this form, you will provide us with background information to understand why you are seeking our services. This form is solely for informational purposes and does not establish a patient-provider relationship or guarantee any treatment plan.

To become a prospective patient, you will need to complete our new patient intake forms which we will send to your email once this contact form is received by us. Your potential appointment will be contingent upon all forms signed, completed and our office verifying your payment method, whether through insurance or private pay. We try our level best to accomodate you for the appointments.

If you are in a psychiatric crisis or experiencing active suicidal thoughts, please call 911 immediately. Your safety is our top priority.

Initial Contact form