Legal Name *

First Name

Last Name

Phone *

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What Service(s) are you Seeking? Check all that apply. *

Need Help with My Current Prescription(s) -- Please Specify Below

Want to Discuss Starting a Medication

MAT services for addiction and substance use

Interested in Non-Pharmaceutical Treatment Options

GeneSight® Genetic Test for Psychotropics

Medical Marijuana Card Approval/Renewal (Cash/Credit, CT Residents Only)

Other (please specify in message below)

What payment option are you interested in? *

Private pay (cash, credit/debit, HSA)

Husky / Medicaid

Commercial health insurance (please upload a picture in the next question)

How did you find out about us? *

Psychology Today

Google Search

Friend or Colleague

Referral (specify below)

What time do you prefer us to contact you? *

Morning

Afternoon

Evening

How urgent do you need to be seen? *

This is not urgent, I can wait to be seen and can be placed on a waiting list if necessary.

I need to be seen immediately and cannot wait 2 weeks or be placed on a waiting list. (This practice is not for you. Please call 911, 988, or go to the nearest emergency room)