NEW PATIENT REQUEST FORM Patient Name * First Name Last Name Phone (###) ### #### Email * Radio * Patient Age Group (Select one) Child (6–12) Adolescent (13–17) Adult (18–64) Checkbox Which services or approaches are you interested in? (Select all that apply) Diagnostic Evaluation (Initial Psychiatric Assessment) Medication Management Brief Supportive Therapy / Counseling Medication + Therapy Combination ADHD Evaluation Pharmacogenetic Testing (gene-based med matching) Supplements / Integrative Approaches Spravato® (Esketamine) – Coming Soon! Membership Plan Other Dropdown * Individual Completing Form Request Patient (Self) Parent Legal Guardian Other Family Member Healthcare Provider Friend/Other Spouse or Partner Thank you!
