Name *

First Name

Last Name

Date of Birth *

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DD

YYYY

Street Address *

Address 1

Address 2

City

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Chief Concerns (Indicate all that apply)

ADD/ADHD

BIPOLAR DISORDER

PTSD

PANIC DISORDER

DEPRESSION

ANXIETY/WORRY

EATING DISORDER

SCHIZOPHRENIA

OTHER (DESCRIBE BELOW)

What services are you interested in for In person Appointment

TELEPSYCHIATRY (ONLINE VIDEO APPOINTMENTS)

Please note that completing this inquiry form does not guarantee an appointment or create a provider-patient relationship. Your inquiry will need to be reviewed to determine if we are a fit for your needs and the providers’ clinical capabilities. We will respond by telephone or e-mail regarding the next steps to schedule your initial appointment. *

I Understand