EmailMe Form - New Patient Appointment Request

Appointment Type *

I am requesting an appointment for medication management.

If you are looking for therapy or counseling, we recommend
contacting your insurance company or searching on Psychology Today.

We are currently accepting patients age 14 and up *

I understand.

I am requesting an appointment for... *

myself.

my child/dependent (age 14-17).

Parent/Guardian Name *

First Last

Parent/Guardian Phone *

### - ### - ####

Is there another parent or guardian that you would like to add?

No

Yes

Parent/Guardian Name (additional contact)

First Last

Parent/Guardian Phone (additional contact)

### - ### - ####

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