Legal Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

What was your sex assigned at birth? *

Male

Female

What Service(s) are you Seeking? Check all that apply. *

Need Help with My Current Prescription(s) -- Please Specify Below

Want to Discuss Starting a Medication

Interested in Non-Pharmaceutical Treatment Options

GeneSight® Genetic Test for Psychotropics

Medical Marijuana Card Approval/Renewal (Cash/Credit, CT Residents Only)

Auricular Acupuncture

Other (please specify in final question)

Are you currently, or have you ever been, diagnosed with or experienced any of the following? Check all that apply. *

Depression

Anxiety

Post-traumatic Stress Disorder (PTSD)

ADD/ADHD

Bipolar Disorder

Borderline Personality Disorder

Schizophrenia

Obsessive Compulsive Disorder (OCD)

Substance Use Disorder

Gender Dysphoria

Eating Disorder

Psychiatric Hospitalization

Autism or Autism Spectrum

Chronic Pain

Other (specify at final question)

How urgent to you need to be seen? *

I need to be seen immediately and I cannot wait a couple of weeks (this practice is not for you, please call 911, go to the ER, or go to a walk-in community mental health clinic).

I can wait a couple weeks to be seen, this is not urgent.

What payment option pertains to you? Select one. *

Private Pay (Credit/Debit or HSA)

Husky Health (CT Medicaid) *Husky needs to be your primary and only health insurance.

How did you find out about us? *

Psychology Today

Google Search

Friend or Colleague

Referral (specify below)

What is your appointment availability and preference? *

Current appointment times are on Tuesdays, Wednesdays, and Thursdays 9AM-5PM. We will try our best to accommodate your preference.

Tuesday Mornings

Tuesday Afternoons

Wednesday Mornings

Wednesday Afternoons

Thursday Mornings

Thursday Afternoons

How do you prefer to have your appointments?

Some insurances and situations require in-person appointments

Telehealth (virtual)

In-person at the Madison, CT office