New Patient Registration

Please complete the form as thoroughly as you can.

What are you registering for?*
- Office Appointment
- Telepsychiatry
Your Personal Information
First Name*
Last Name*
Preferred Name
Email*
Phone Number*
Marital Status
Gender Identity*
Address*
Street Address City State ZIP Code
Preferred Language
Race
Ethnicity
Education
Date of Birth*
MM slash DD slash YYYY
List the psychiatric and/or substance abuse diagnoses you wish for me to treat:*
Appointment Reminders*
- Email
- Text
- Voicemail
Check all that apply.
Emergency Contact Person
Full Name
First Last
Phone Number
Email
Pharmacy
Pharmacy Phone
Medicare Patient:
- I am a Medicare Patient
Proof of Identity and Current Address
- Upload a photo of your driver's license, passport, or government-issued photo ID.
- Upload a photo of a current utility bill or piece of mail that can confirm your name and address.
Drop files here or

Accepted file types: jpg, png, pdf, zip, doc, docx, Max. file size: 32 MB, Max. files: 3.
Medicare Patients
- Upload a photo of your medicare card and any supplemental insurance.
Drop files here or

Accepted file types: jpg, png, pdf, zip, doc, docx, Max. file size: 32 MB, Max. files: 3.