Contact UsNew Patient Request

Name (required)

Email (required)

Primary Insurance Provider (required)

Insurance ID Number (required)

Primary Phone # (xxx) xxx-xxx (required)

Date of Birth (MM/DD/YYYY) (required)

How did you hear about our office? (required)

Are you currently in treatment with a Psychiatrist or Psychiatric Nurse Practitioner?
YesNo

Are you currently seeing a therapist?
YesNo

Are you currently on medications for mental health illnesses?
YesNo

Have you recently (within the last year) been treated at a detox/rehabilitation facility or been admitted to an IOP/PHP or inpatient facility for mental health reasons?
YesNo

Reason for Visit

We routinely check the CT prescription monitoring program for controlled substances before seeing all new patients. Our office policy also includes urine toxicology screens at the start of and/or during the treatment process for safe prescribing practices.