Contact Us
Please fill out the form below and we'll get back to you as soon as possible.
I am a
*
Provider
Clinic
Payor
Patient
Other
Full Name:
*
Dr.
Mr.
Mrs.
Ms.
Other
Prefix
First Name
Last Name
Email:
*
Phone Number
-
Area Code
Phone Number
Professional Title
*
MD
DO
APRN
PA
LCSW
Other
Other Title
Board Certification (Select all that apply)
*
Board certified general psychiatry
Board certified child and adolescent psychiatry
Board eligible general psychiatry
Board eligible child and adolescent psychiatry
Board certified addictions psychiatry
Board eligible addictions psychiatry
Board certified geriatric psychiatry
Board eligible geriatric psychiatry
Certifications (Select all that apply)
*
PMHNP
DNP
FNP
Other
Other Certification
What states are you licensed in? (Select all that apply)
*
Organization
*
(Ex: Cherry Lane Health Clinic)
What ages do you treat? (Please list minimum and maximum age below)
Min age
Max age
Age Specialties
Reason for Contacting
*
I’m interested in telepsychiatry for my organization or facility (hospital, clinic, etc.)
I’m an existing customer with Genoa Telepsychiatry
Other
Reason for Contacting
*
I’m interested in receiving care with Genoa Telepsychiatry
Other
How did you hear about us?
Google Search
Conference
Email
Facebook
Indeed
LinkedIn
Referred by friend/colleague
Newsletter
Other
Who referred you?
Message
What state are you located in?
Submit
Should be Empty: