UCA Appointment Request

If you have an emergency, dial 911. If you are having a mental health crisis, call 800-273-8255.

Please correct the errors described below.
Please include any past diagnoses here.
If you have a specific therapy method (EMDR, etc.) you are interested in, please indicate it here.

Any information included on this form, is sent to us via a HIPAA-compliant encryption software, and treated with the utmost confidentiality.

Your information will be encrypted.

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