Name *

First Name

Last Name

Phone *

(###)

###

####

I have reviewed Journey to Wellness Fees as posted *

Yes, I have reviewed the fee list on the Services page and I am willing and able to pay the fees.

No, I have not reviewed the fees or am not able or willing to pay them. I will seek out a different psychiatrist and not be contacted.

Acknowledgement *

I acknowledge that an initial free phone call will not establish a provider-patient relationship and the intention of this call is to offer guidance regarding treatment track and answer general questions, rather than offer specific medical advice.