Answer the questions to complete registration

What is the name and age of the person seeking care?

Name is required
Patient safety and well being remain the top priority of Synergy Mental Wellness. Based on your history/symptoms/requirements we would not be able to adequately meet your needs and feel you would be best served by a local psychiatric provider who can provide the appropriate level of care. Psychologytoday.com provides a list of providers in your area based off a search with you zip code/city. Thank you.

Any history of schizophrenia, schizoaffective, any diagnosis with psychotic features and/or ever experienced an episode of psychosis?

Have you ever been involuntarily committed to an inpatient unit for psychiatric crisis or have any history of suicide attempts?

Are you seeking care for the purpose of establishing disability, custody, or other court related concerns?

Are you dealing with any legal issues at this time, or in the past?

Have you received psychiatric care before?

Why are you seeking care now? Check appropriate answers below:

Anxiety

ADHD

Depression

Insomnia

Other

Are you taking any psychiatric medication?

Please list ALL current psychiatric medication and dosages

Please list all previous psychiatric meds

Are you taking any other medication?

Please list ALL other medication you currently take and the reason you take it

Is there any additional information you would like us to know so we may better assist you?

Please enter your email and phone number.

Phone number is required

Thank you.

If we are able to offer an appointment, we will get in touch with you soon.