Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *Please enter date of birth in MMDDYYYY formatEmail *Enter the best email to contact youPhone Number *Enter the best number to contact youHave you been experiencing any worsening mental health symptoms? *YesNoHave you had any recent hospitalizations or emergency room visits for psychiatric concerns? *YesNoIf you answered "yes" to above, please describe *Have you been diagnosed with any mental health conditions? *YesNoIf you answered "yes" to above, please describe * If pay? visits What symptoms are you currently experiencing? *DepressionAnxietyMood SwingsHallucinationsParanoiaPTSDOtherIf you answered "other" above, please describeHave your mental health symptoms affected your daily life? *YesNoHave you had thoughts of harming yourself or others? *YesNo Have you ever attempted suicide or engaged in self-harm? *YesNoIf you answered "yes" to above, when was the most recent time? *Do you have a plan or intent to harm yourself or others now? *YesNoWhat is the best time of day to contact you? *How would you like to pay? *Self-pay in FullDeposit & InstallmentsPlease check my insurance (Enter provider & ID# in comments)Comments or Questions *Submit
