Request a new patient appointment

We appreciate your interest in our office. This is the first step in determining whether we are able to help. We will not share this information with any third party.

Your full name

Prefer to be called

Email address

Phone number

Date of birth

What would you like to be seen for? Please include any previous psychiatric diagnoses. What substances, if any, are causing problems in your life?

Are you currently prescribed any medications that a psychiatrist might prescribe (i.e., for mood, anxiety, ADHD, sleep, etc.)? If so, please list the medications along with the dosages and frequencies.

Have you been hospitalized for psychiatric treatment before? If so, how many times? When and where was the last one?

Have you been treated for addiction before? If so, when and where were you treated?

Because I take physician-patient confidentiality seriously, I ask that any patients or prospective patients review our Email Policy regarding communicating by email.

I agree to the Email Policy