New Patient Evaluation Request
The form usually takes under two minutes to fill out, and briefly asks what the concerns are and what kind of treatment is requested.
Before downloading, please note:
- If you or your child is experiencing any emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter, do not use this form. Instead call 911 or go to your closest emergency room.
- This is an evaluation request form only, and does not in and of itself establish a physician-patient relationship.
- If I have availability I will call you within two business days. If you do not hear back from me, it unfortunately means that I do not have availability at this time, and the information you give will be securely erased.
- Download the form, then fill it out in Adobe Reader, a free program (download here if you don’t have it). Even if the form appears in your browser, do not fill the form out in your browser as some browsers will not save it with the information you have typed. To be sure, download first, then open in Adobe Reader.