New Patient Please complete the form below, and we will get back to you. Thank you! First and Last name Your email Telephone Number Date of Birth Preferred Appointment Delivery TelemedicineIn Person Street Address, City, State and Zip Code Insurance Company ID number and Group number Insurance Phone number Primary Insured Name and Date of Birth Secondary Insurance Name (Please Note: we are not contracted with OHP/Medicaid. Therefore, if you have OHP/Medicaid, you will be responsible for any co-pays.) My Previous Mental Health Diagnosis are Please check any diagnosis or symptoms that you are currently struggling with Aggression / AngerAlcohol DependenceAnxiety / Panic AttacksDepressionDistractibilityEating DisorderElevated MoodFatigueHallucinationsImpulsivityIrritabilityLoneliness / WithdrawingPhobias / FearsSleep ProblemsThoughts of suicide or self-harmWorrying / HopelessnessStressors related to LGBTQ/ TransgenderOthers Any additional information or concerns that you would like to share with us? (both mental health and physical health conditions)
