[2026] Contact Alis Family Psych

Contact Alis Family Psych
Is this a medical or psychiatric emergency?
This form is for non-urgent communication only. If you are experiencing a mental health crisis, severe side effects, or a medical emergency, please dial 911, dial 988 (Suicide & Crisis Lifeline), or go to the nearest emergency room immediately.
Are you a current patient of Alis Family Psych?
What is your primary reason for contacting us?
Patient Full Name

Patient's Legal First NamePatient Last Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email
example@example.com
Securely upload your new Insurance Card (Front & Back)

Cancelof
Who is completing this form?
Parent/Guardian Full Name
Parent/Guardian Email
Parent/Guardian Phone
🚨 Action Required for Medication Refills 🚨

To ensure your refill is processed quickly and safely, you must use our dedicated clinical request portal.

👉 CLICK HERE TO OPEN THE MEDICATION REFILL FORM
Please describe your issue briefly.

0/500
Referring Provider Name
Clinic/Practice Name
Clinic NPI
Contact Email & Phone
Please securely upload the patient's face sheet and recent clinical notes here (PDF/DOC).

Cancelof
source
Please note:
Our team checks this portal Monday through Friday, 8:00 AM to 5:00 PM EST.
Providers only approve medication and clinical requests Monday through Thursday.
Please expect a 1 to 2 business day turnaround for standard questions.
Need a refill? Submit your request a full week early so you do not run out.
We do not offer on call or crisis services.
If you are having a medical emergency, call 911 immediately.
Should be Empty:

Contact Alis Family Psych

🚨 Action Required for Medication Refills 🚨