Take Your First Step Towards a Brighter Future Send us a Request, and we'll get back to you Shortly You can fill out the patient registration form below with your personal information and request the next available appointment online or over the phone Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number *Date of Birth *Address *City *Zip *Multipule Choice *InsuredSelf PayMedical Service *(TMS) Transcranial Magnetic StimulationESKETAMINEMedication ManagmentPsychotherapyOtherName of InsuranceName and ID Number of Secondary Insurance (If applicable)Member IDInsurance phone number from the back of the cardDriver License / State ID CardSocial Security NumberReason for the visit *How did you find about us Medical ReferralZocdocPsychiatry TodayOtherI agree *To settle all bills as they are presented. For members with private insurance plans, I will cover all deductibles, co-payments, and patient responsibility portions of the bill, in accordance with the specific plan. I acknowledge and agree to pay a cancellation fee of $55 for any appointment cancelled with less than 24-hour notice. Additionally, I understand that it is my responsibility to inform the office promptly of any changes in my insurance coverage.I agree *We prioritize the security and privacy of all communications by utilizing 256-bit AES encryption. Our stringent measures ensure compliance with all HIPAA regulations pertaining to privacy and security. The confidentiality laws governing medical information also extend to Telepsychiatry consultations. No information or images from the Telepsychiatry consultation that could identify you will be disclosed to researchers or any other entities without your explicit consent. By giving your consent, you are authorizing your participation in psychiatric treatment that employs teleconferencing equipment.Send Request Having trouble filling our application online? Please call our office 866-247-4292 Or Use this Form Instead