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  • 2 Minute Fit Check: Qualify for a Free Clinical Consultation

    A few quick questions to get to know you and make sure we're the right fit and can care for you safely. Please answer honestly. All information shared is confidential.
  • 1. Our care is built around the interaction between hormones and brain health. Which best describes you?*
  • 2. Which of these are you experiencing? (Select all that apply)*
  • 3. Do you notice your focus, mood, or energy shift with your cycle, pregnancy or postpartum, or perimenopause / menopause?*
  • 4. Where is this affecting you most? (Select all that apply)*
  • 5. What is your current ADHD status? (self-reported)*
  • 6. Are you currently taking any ADHD or psychiatric medication?*
  • Safety Reminder: If you are experiencing a medical or mental health emergency, or having thoughts of suicide or self-harm, call or text 988, call 911, or go to your nearest emergency room. This platform is not for emergencies and does not provide crisis care.

  • Please share your contact details to finalize.

    Clarity starts on the other side of this form.

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Safety Reminder: If you are experiencing a medical or mental health emergency, or having thoughts of suicide or self-harm, call or text 988, call 911, or go to your nearest emergency room. This platform is not for emergencies and does not provide crisis care.

  • Almost there! Just making sure we are a good fit for you.

  • Some of our services (for example, group coaching, $159/month) is not covered by insurance. Are you willing to pay out of pocket for care that isn’t covered?*
  • Are you currently receiving treatment via transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), or ketamine?*
  • In the past 12 months, have you had a psychiatric hospitalization (voluntary or involuntary), intensive outpatient program (IOP), partial hospitalization program (PHP), residential program, detox or rehab for any reason?*
  • Care with us is delivered by live video call only — this is required for compliance purposes. Are you willing to receive care this way?*
  • Are you currently a resident of Virginia?*
  • What is your age range?*
  • Safety Reminder: If you are experiencing a medical or mental health emergency, or having thoughts of suicide or self-harm, call or text 988, call 911, or go to your nearest emergency room. This platform is not for emergencies and does not provide crisis care.
  • Safety Reminder: If you are experiencing a medical or mental health emergency, or having thoughts of suicide or self-harm, call or text 988, call 911, or go to your nearest emergency room. This platform is not for emergencies and does not provide crisis care.
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