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New Patient Inquiry Form 

Please fill out this form and we will contact you as soon as we can. 

Appointment Request

OUR NEXT AVAILABLE APPOINTMENTS ARE DECEMBER 2026

Disclaimer: Providers review inquires. As a small outpatient clinic without emergency or after-hours crisis services, we may not always be the right fit for every patient, and when we aren’t, we’ll share referrals. This reflects the care we can offer and our goal is to make sure every person gets the care that serves them best. 

Patient date of birth
Month
Day
Year
Payment Method

Insurance Information

Psychiatric History

These questions help us make sure we can offer the level of care that's right for you. Your answers are confidential. If you are in crisis right now, please call/text 988 or 911. This form is not monitored in real time.

Have you ever attempted suicide?
Yes
No
If yes, when was the most recent attempt?
Have you ever intentionally hurt yourself without intending to die (for example cutting)
Yes
No
In the past 12 months have you had any of the following (check all that apply)
In the past month have you used any substances? (this includes alcohol and marijuana)
In the last 12 months have you engaged in substance use treatment? (ex rehab or a dual diagnosis program)

Disclaimer: completing this inquiry form does not establish you as a new patient. Our intake coordinator will contact you upon receipt of the completed form. If you are having an emergency please call 911, 988, or head to your nearest ER. We appreciate your interest.

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