I am seeking therapy services

I am seeking a neurological evaluation/testing

Referral

Have you been given a mental health diagnosis in the past?

Yes No

if you answered yes to the question above, please explain

Have you recieved mental health treatment in the past
Yes No

if you responded yes to the question above, please explain?

Current Medication(s) and psychiatrist (if applicable)

Current Primary Care Physician (PCP)

Has anyone in your family been given a mental health diagnosis?

Days of the week I'm available for appointments

Please note that our clinicians do NOT work evenings or weekends and there is limited availability for evening and weekend appointments

Monday

Tuesday

Wednesday

Thursday

Friday

Weekends

Times I am available for appointments

Mornings

Afternoons

Evenings