See Our Healthcare Practiceâ€™s Calendar of Availability

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Step 1: Fill out our Pre-Screen Form

If you are a new patient, fill out our Pre-Screen Form.Â Please contact us at (603) 305-7076 or at [email protected] for more information. New clients with confirmed insurance coverage, please complete pre-screen form and press submit button. Contact your Primary Care Provider to send a referral to your insurance company (if your insurance requires this) and a copy to this provider.For self pay clients, please complete STEP 2.Â Note: If you already have insurance â€“ DO NOT PAY. Insurance covered patients please stop at STEP 1. For new clients who request a refund after payment, a certain % will be deducted for re-processing and administrative fee.Â

Already A Patient? Pay Here!

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email Address:*
Pharmacy Location*
Pharmacy Used*
Primary Care Provider:*
Primary Care Location:*
Primary Insurance information:*
Primary Insurance Phone No.*
Insurance No.*
Secondary Insurance:*
Secondary Insurance Phone No.*
Insurance No.*
Social Security No.*
Is the provider covered under your insurance plan?*
- Yes
- No
What issue(s) have led you to seek a medication evaluation? What is your psychiatric diagnosis (if known)?*
Are you currently seeing a therapist? If so, for how long and how often do you see your therapist?*
Are you currently taking any psychiatric medication(s)? If so, please list them.*
Have you taken any psychiatric medications in the past that you are no longer taking? Please list them.*
Does you have a history of self-harming behaviors or suicidal thoughts? If so, please describe*
Have you ever been to an emergency room for a psychiatric evaluation? If so, what was the outcome of this/these evaluation(s)?*
Have you ever been in a psychiatric hospital?*
- Yes
- No
Have you ever had a problem with drug or alcohol use?*
- Yes
- No
Have you ever engaged in disordered eating (binging/purging/restricting)?*
- Yes
- No
Are you currently being treated for a mental health condition?*
- Yes
- No
What non-psychiatric medications, if any, are you currently taking?*
Have you ever seen a psychiatrist specialist? If so, what diagnosis was given and what treatment was required?*
How soon you do want an appointment?*

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