New Client Evaluation

This form is NOT for Texas residents. Click HERE to read policies.

Evaluations are reviewed during our normal business hours, Monday-Friday 8 AM - 4 PM CST (excluding major holidays). You will be contacted within one business day, regarding your submission.

Please double-check for accuracy: Spelling of first and last name, date of birth, and email address.

First Name

Last Name

Date Of Birth (Serving ages 18-65; as stated under Policies).

Phone Number

What insurance do you carry? (Please review policies for the plans currently accepted.)

Please provide BRIEF statement explaining why you are seeking treatment. If you have current, or previous, psychiatric diagnoses, please list them here:

Have you been hospitalized for psychiatric reasons? If yes, briefly indicate when, and why:

List current psychiatric medications.

List previous psychiatric medications.

We have received your submission. You will hear from us within one business day.

Kuponya

Telepsychiatry

Kuponya... - Swahili.... English translation, "healing; to heal"

New Client Evaluation

This form is NOT for Texas residents. Click HERE to read policies.

Evaluations are reviewed during our normal business hours, Monday-Friday 8 AM - 4 PM CST (excluding major holidays). You will be contacted within one business day, regarding your submission.

Please double-check for accuracy: Spelling of first and last name, date of birth, and email address.

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New Client Evaluation

This form is NOT for Texas residents. Click HERE to read policies.

​

​

Evaluations are reviewed during our normal business hours, Monday-Friday 8 AM - 4 PM CST (excluding major holidays). You will be contacted within one business day, regarding your submission.

Please double-check for accuracy: Spelling of first and last name, date of birth, and email address.