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New Patient Inquiry

Thank you for your interest in scheduling a new patient appointment. In order to schedule your appointment, we request that all new patients submit a brief inquiry online. Please submit your inquiry and we will contact you when we are accepting new patients. 

*If you are in crisis and need of immediate care, please call 911 or go to your nearest emergency room. 

Please be advised that our next available appointment may be up to 4-6

weeks. We look forward to serving you.

First Name*

Last Name*

E-mail Address*

Date of Birth*


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Phone Number*

Address Line 1*

Address Line 2*



Zip Code*

Please select your insurance company below:*

Any psychiatric hospitalizations?*

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If so, how many?*

Please provide a brief description as to the reason for your visit:*

Current or Recent Medications:*

Who referred you to our practice?*

Appointment Day Preference:*

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Time Preference:*

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