Appointment Request Form

Full Name*

First NameLast Name

Contact Number*

Please enter a valid phone number.

Email Address*

example@example.com

Age Range*

How do you plan to pay for services*

InauranceSelf Pay

Referral Source*

What are you looking to get help with?*

Medication ManagementTalk TherapySpravato ConsultMedical Marijuana Consult

Are you currently taking medications for your mental health?*

YesNo

What time of day is best for you?*

MorningsAfternoonsFlexible

Terms & Conditions – Appointment Request

By submitting this form, you acknowledge and agree that:

This form is for appointment requests only and does not establish a provider–patient relationship.
Required medical, insurance, and identification information will be collected securely through our patient portal after scheduling.
You authorize Eccentric Minds Health & Wellness PLLC to contact you by phone, email, or text regarding scheduling and next steps.
If submitted for a minor, a parent or legal guardian must participate in scheduling and complete required consent forms.