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Thank you for your interest in our practice.

Please complete the form below:

Birthday
Month
Day
Year

Please provide detailed mental health history, including any history of psychiatric hospitalizations.

Are you currently or do you have a history of substance abuse?

Please list all psychiatric medications you are currently prescribed.

Ex: Primary care doctor, OBGYN, previous psychiatrist.

Are you in a crisis? (Emergency)
Yes
No
Symptoms: Please select all that apply to your reason for seeking care.

Your request will be reviewed and we will be in touch! If you have other questions or would like to discuss private fee rates or out-of-network benefits, please email us directly at adminsupport@claritymbwellness.com

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