Counseling For Your Mental Well Being

Telehealth Patient Access

Fill out the form below to get started with your doxy.me telehealth appointment with your clinician.

Telehealth Authorization
We know the current situation with COVID-19 has made challenging situations even more difficult. Our top priority is to continue to meet your mental wellness needs.

At this time, we are practicing social distancing recommendations and enacting best practices that will allow us to serve you while keeping everyone’s health and safety a priority.

Our office is temporarily transitioning to telehealth appointments provided offsite.
Patient Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Email*
I have been advised of and agree to telehealth visits with:*
Date*
MM slash DD slash YYYY
SignatureSignature of Patient/or Responsible Party for Patient*

Save and Continue Later