New Client Evaluation

Click HERE for current insurance plans accepted and states served , and HERE for current policies.

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

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

First Name

Last Name

Serving ages 18-65 (as stated under Policies).

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

Are you currently attending therapy/counseling sessions?

Yes

List current psychiatric medications. If none, list previous medications. Please list other medications you are prescribed as well:

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

What insurance do you carry? (Review home page for current plans accepted.)

We've received your submission. You'll hear from us within one business day.

Kuponya

Telepsychiatry

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

New Client Evaluation

Click HERE for current insurance plans accepted and states served , and HERE for current policies.

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

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

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New Client Evaluation

Click HERE for current insurance plans accepted and states served , and HERE for current policies.

​

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

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