Initial Registration Form

Registration

Any information you enter is private, confidential, and encrypted. It does not mean you have any obligation to schedule an initial consultation, that you or your insurer will be charged, nor does it obligate us to provide you medical services. This is information we require to initiate the registration process.
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Gender*
Gender other - Please specify*
Email*
A private and secure email address. Make sure only you have access to this email address
Phone Number*
A phone number that you can privately communicate and receive messages on
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Psychiatrist you'd like to see*

I'm not sureDr. DuqueDr. BrarDr. Deranja
Brief description of what you're seeking treatment for
280 Characters
Choose payment method*

Insurance (In-Network: See our FAQ for accepted insurance carriers)Insurance (Out-of-Network: See our FAQ for how this works)Self pay
Insurance card information*

Upload picture of your card (If you're on a desktop or laptop)Take a picture of your card (If you're on a phone or tablet)
Insurance Card Front*
Insurance Card Back*
Upload Insurance Card Front*

Cancelof
Upload Insurance Card Back*

Cancelof
Do you have supplemental or secondary insurance*

YesNo
Supplemental Insurance card information*

Upload picture of your card (If you're on a desktop or laptop)Take a picture of your card (If you're on a phone or tablet)
Supplemental Insurance Card Front*
Supplemental Insurance Card Back*
Upload Supplemental Insurance Card Front*

Cancelof
Upload Supplemental Insurance Card Back*

Cancelof
Should be Empty: