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
Date
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
The fastest way to get your refill is through the system portal.

1. Click here to log in.

2. Click Messages at the top.

3. Type "I need a refill" and hit send to alert the provider.

Locked out of your portal? Click here to use our backup 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
Should be Empty: