Now Accepting New Patients

Inquiry Form

Fill out the form below and I will respond in 1-2 business days.

Name

First Name

Last Name

Phone

(###)

###

####

How you learned about my practice

Payor Information

Select if you have one of the insurance carriers that I accept or if you plan to pay privately for sessions. Please note, I am not in network with medicare or medicaid.

Historical Information

Please provide a brief summary of your psychiatric treatment history (ie have you seen a psychiatrist before or taken psychiatric medication in the past? Have you ever been hospitalized or done psychotherapy?)

Current Information

Please provide a brief summary of what you are currently looking for help with. Include any current medications or if you are currently in therapy. If you are currently under the care of psychiatric provider, please include some information about the reason you'd like to be seen by me (moving states/cities, change in insurance, looking for someone with different area of focus, etc)