Name *

First Name

Last Name

Phone *

(###)

###

####

Is it okay to leave a voicemail at this number? *

Yes

No

Disclaimer *

The information in this form is sent to Sound Mind Psychiatry LLC’s unencrypted email account. There can be delays or failures in sending information via electronic communication. Privacy cannot be guaranteed, although safeguards are taken to protect this information as much as possible. Submission of this form does not create a patient- provider relationship. By checking this box, I acknowledge that I have read and agree to the risks and conditions described above.

I understand and agree to the above.