Schedule an Assessment Form

* Required Information

Please fill out this brief survey and someone from our team will contact you within 48 business hours!

We accept most major insurance

Self Pay: Initial Evaluation: $260 | Follow up: $130

Provider you are requesting an appointment with *

Please select what insurance plan you have or if you are self-paying. *

This will let me know if I need to bother you with collecting insurance details!

First Name *

Last Name *

Date of Birth *

Phone *

Email *

Reason for appointment request *

What are you looking for in your mental health journey? *

Please list all previous psychiatric diagnoses *

List if you have ever been treated for depression, anxiety, PTSD, schizophrenia, substance use, suicidal thinking, etc..?

Are you pregnant or planning to be? *

Yes

Have you ever been hospitalized (stayed for longer than two days) in a mental health hospital/psych ward? *

Yes

When was your most recent hospitalization? *

Put N/A if you answered NO

Current Medications? *

Please list all current prescriptions for our provider to review! Put "none" if you don't take anything.

We offer psychiatric medication management services + plus holistic wellness coordinations. We are not a crisis/emergency/detox/MAT center.

If you are having a mental health crisis (active suicidal thoughts/plans, auditory and/or visual hallucinations, detoxing/withdrawing from substances), please call 911, go to your nearest ER, or find the ER/Crisis Resources menu and go to one of the options listed there.

By submitting this form you agree to the terms of the Privacy Policy.

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