I acknowledge that completion or submission of this form does not constitute acceptance as a patient or guarantee an evaluation.*

We do our best to respond to your request within 48 hours. Please note that new patient appointments are booked approximately a month in advance.*

I understand that this practice does not provide treatment for substance use or substance abuse disorders. If concerns related to substance use arise, I may be referred to an appropriate specialist or treatment program.*

I understand that this provider does not provide crisis care or urgent care. If I am experiencing an urgent or psychiatric emergency, I need to seek immediate help through emergency resources such as calling 911 or going to the nearest emergency department.*

I understand this provider only accepts patients who are 21 years and older.*