User Registration Form

Psych History

Self harm history

Current Medications

all including psychiatry

I acknowledge that in order to make the appointment I will make a payment of $40.00, if I choose not to show up for the telehealth appointment with out 48 hour notice, I will not be reimbursed the 40.00 , however, When I come to my appointment, the 40.00 will be credited to your account toward your copay or cash pay.