Patient First Name *

Patient Last Name *

Patient Date of birth *

Patient Email *

Patient Phone *

Treatment Type *

Preferred Location *

Primary Diagnosis *

Patients with schizophrenia and/or currently in manic episode are not eligible for treatment

Has the patient reported prescribed medications or treatments as being ineffective in treating their symptoms?

Patient's Current Medications for Treating Depression, Anxiety, Pain

Has the patient been prescribed more than one medication or treatment for their diagnosis?

Referring Provider *

Provider's Specialty *

Provider's Phone *

Provider's Email *

Comments or Concerns

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