New Patient Inquiry

Thank you for your interest in our practice! Please provide the following information to complete your request for new patient evaluation. Please be advised we are primarily a medication management practice and only provide brief psychotherapy in conjunction with medication monitoring. Please allow our office 5 business days to review your inquiry.

Our initial evaluations are scheduled for 90 minutes for adults and for patients under the age of 18. We do require a fully refundable $100 deposit in order to schedule a new patient evaluation. The deposit can be credited towards future copays or refunded to you after your initial evaluation is complete.

Patient Name

First Name

Last Name

Parent / Guardian (if patient < 18 yo)

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Address

Insurance Carrier

Please note we do not accept Medicaid or Medicare.

Insurance Member ID

If you do not have insurance enter "private pay"

Provider Preference

Reason for visit

Any current health problems or substance use disorder?

All current medications

Referred by

Other comments