Secure Contact Form

Please complete the contact form below and click "submit" when you are done. We will review this information and contact you regarding next steps, or clarification if needed.

We look forward to working with you.

If you have immediate safety concerns, please seek emergency psychiatric services at your nearest emergency room.

Patient's Name:

Patient's Date of Birth:

Your Name and Relationship to Patient:

Phone number

Email address

Referral source (if different than above)?

What are your referral questons/concerns?

Please upload any additional/supporting documentation if needed.

Add file

Please upload a file

By submitting this form, I acknowledge and agree that the information I provide will be transmitted via an encrypted method. While reasonable measures are taken to safeguard my information, I understand that no method of electronic transmission is completely without risk, and I assume any associated risks in submitting my information.

I consent to the use of this form for initial contact purposes and understand that it is intended solely for preliminary inquiries. I acknowledge that submitting this form does not create a provider-patient relationship, nor does it guarantee confidentiality beyond the security measures in place. I further agree that the practice shall not be held liable for any unauthorized access to my information during transmission, and I understand that I may choose to contact the practice via phone or other methods if I prefer not to use electronic communication.

By submitting this form, I confirm that I have read and understand the terms of this consent.

THANK YOU!

Your information will be encrypted.

Secure Contact Form

THANK YOU!

Empowered Minds Neuropsychology