Patient Information

New patients are required to complete the forms below:

New patient appointments are for Evaluation and Medication Management. Please note that we do not
provide disability evaluations, Workers Compensation, parenting evaluations or any other forensic
services. We do not provide letters for emotional support animals.

To request an appointment please fill out the form below or Call 972-972-4850.








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YesNo

Payment Information





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We do not accept patients with coverage through Medicaid at this time.

Reason For Visit



Attention/ADHDDepressionBipolarPTSDGriefAnxietyPanic AttacksSocial AnxietyObsessions or Compulsions /OCDPhobiasAgoraphobiaInsomniaNightmaresBorderline Personality DisorderPersonality DisorderEating DisorderParanoiaHallucinationsDelusions (false beliefs)Schizophrenia / SchizoaffectiveDrug Addiction (in recovery or wanting to quit)Drug Addiction (currently using)Alcohol Abuse (in recovery or wanting to quit)Alcohol Abuse (still drinking)Victim of ViolenceVictim of Sexual AbuseExtreme StressRecent Traumatic ExperieinceChronic/Severe IllnessChronic PainChronic FatigueSexual IssuesMarital ConcensParenting IssuesWork-Related IssuesGender Dysphoria or Transgender IssuesCurrently PregnantPlanning to Become PregnantPostpartum IssuesPremenstrual or Menopause IssuesDevelopmental DelayAutismBrain Injury or DementiaLegal ProblemsAnger ProblemsViolent Thoughts or BehaviorSuicidal ThoughtsSelf Harm (cutting, burning, etc)Suicide Attempt in Last YearPsychiatric Hospitalization in Last Year (involuntary)Psychiatric hospitalization in Last Year (voluntary)










Practice Details

I have a primary care provider and have been seen in the last two years.
I understand the no-show / late cancelation fee.
I understand.
I understand.

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