New Patients

Registration Forms

Select the form that fits your needs below, complete the fields, and our team will follow up promptly. Prefer to talk first? Call us at (207) 910-6580.

Note: These forms collect protected health information. Before going live, connect a HIPAA-compliant form handler (with a signed Business Associate Agreement). Submissions are currently not transmitted.

General Inquiry Form

Have a question? Send us a note and we'll get back to you promptly.

Psychiatry & Medication Management Inquiry Form

For new psychiatry and medication management patients. Fields marked * are required.

Your Information

Insurance

Do you have insurance?
Do you have secondary insurance?

Medications & Providers

Do you have a Primary Care Doctor?
Do you have a Psychiatrist?
Do you have a Therapist?

Referral

Individual Therapy Inquiry Form

For new individual therapy patients. Fields marked * are required.

Your Information

Insurance

Do you have insurance?
Do you have secondary insurance?

Background

Do you have a therapist?

TMS Registration Form

For patients registering for Transcranial Magnetic Stimulation (TMS) therapy. Fields marked * are required.

Your Information

Insurance

Do you have insurance?
Do you have secondary insurance?

Current Providers

Do you have a Primary Care Doctor?
Do you have a Psychiatrist?
Do you have a Therapist?

TMS Safety Screening

Do you have any metal in your head, neck, or face area? (e.g., a steel plate in your skull) *
Do you have a history of seizures or a seizure disorder? *
Do you have any implants such as a vagus nerve stimulator or a pacemaker? *
Is there any chance that you're currently pregnant? *
Are you currently or have you ever been diagnosed with Bipolar Disorder? *
Have you ever experienced psychotic symptoms such as hallucinations or paranoia? *
Do you have a history of severe head trauma, dementia, or tumors in the Central Nervous System (brain)? *
Do you currently have any issues with substance abuse/addiction? *

Current Medications

Medications Tried in the Past

Referral

Spravato Inquiry Form

For patients inquiring about Spravato (esketamine) treatment. Fields marked * are required.

Your Information

Insurance

Do you have insurance?
Do you have secondary insurance?

Current Providers

Do you have a Primary Care Doctor?
Do you have a Psychiatrist?
Do you have a Therapist?

Medical Screening

Do you have a history of aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial and peripheral arterial vessels) or arteriovenous malformation? *
Do you have a history of intracerebral hemorrhage? *
Do you have a hypersensitivity to esketamine or any of the excipients? *
Do you currently have any issues with substance abuse/addiction? *
Are you currently on any medications? *

Medications Tried in the Past

Referral

IOP / PHP Referral Form

For referring providers. Please complete this form to refer a patient to our Intensive Outpatient (IOP) or Partial Hospitalization (PHP) program. Questions? Call (207) 910-6580.

Demographic Information

Insurance Information

Referral Source

Clinical Information

Clinical Goals & Diagnoses

Has the patient agreed to participate in our IOP if accepted?
Is substance use an active concern?
Is an eating disorder an active concern?

Substance Use (current and history of problematic use)

Medications & Medical History

Is the patient compliant with medications?

Current Outpatient Treatment

By submitting a form you agree to be contacted by our team. We take your privacy seriously — see our Privacy Policy and HIPAA Notice. If you are in crisis, call or text 988.