Pre-Registration FormPlease use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!Name* First Last How did you hear about us?*Friend or FamilyPrevious PatientPrimary DoctorSMHWI WebsiteGoogleFacebookLinkedInPsychology TodayOtherWho referred you?*Primary Medical Provider*Current Insurance*Secondary InsurancePhone*Email* Preferred Date* Date Format: MM slash DD slash YYYY Preferred TimeMorningAfternoonEveningNature of VisitCAPTCHAEmailThis field is for validation purposes and should be left unchanged.