UCA Appointment Request

If you have an emergency, dial 911. If you are having a mental health crisis, call 800-273-8255. We are not accepting new patients at this time. Complete this form to receive referrals.

Please correct the errors described below.

We are not accepting new patients at this time. Complete this form to receive referrals.

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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