Please read carefully before completing this form:
This practice provides outpatient medication management only.
Completion of this form does not establish a provider–patient relationship and does not guarantee evaluation or acceptance into the practice. Only individuals who meet established clinical and administrative criteria will be asked to proceed. Incomplete, inaccurate, or inconsistent information may result in denial of the request.
We do not treat substance use disorders, as these require a higher level of care.
Emergencies
This is not an emergency service and we do not offer urgent or same-day visits, have providers on call, and handle all patient requests during business hours ONLY.
If you are experiencing a psychiatric emergency or thoughts of harming yourself or others, call 988 or CALL 911 go to the nearest emergency room immediately.
Practice Information & Policies
Financial Policy:
- A valid form of payment is required on file at all times
- Copays are due at the time of service
- Patients must remain in good financial standing to continue care
Cancellation Policy:
- We strictly enforce our cancellation and missed appointment policy, including applicable fees.
Communication:
- All correspondence regarding your intake request will be sent to the email address provided.