Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Sex (on file with insurance) *

Female

Male

Provider Preference *

No Preference

Ashley McKenzie, PMHNP

Dr. Nelly Kangethe, PMHNP

Ruth Ogbans, PMHNP

John Faulkner, PMHNP

John Faulkner, PMHNP

Laurie Lawhorn, LCSW

Rick Suskind, LCPC

ANY AVAILABLE - Medication Management

ANY AVAILABLE - Therapy

Type of Visit

No Preference

Telehealth (Online)

In-Person

Type of Treatment

Therapy Only

Medication Management

Unsure

Statement of Understanding *

By submitting this form, this does not constitute a patient-provider relationship. This form is also sent via traditional email methods, do not submit PHI or confidential medical information. Insurance policy information is not considered PHI or confidential medical information.

I agree

I do not agree