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Please complete the following form.

Upon completion, you will be able to

book an intake appointment.

For which of the following

are you seeking treatment?

*Only available with Proactive Complete℠

"I have read The Proactive Approach℠

My Promise, and Options & Pricing.

I know you do not accept insurance.”

Yes, I have read the required pages!

If you have not read these pages and polices,

please do so before continuing.

"I understand I must complete all intake documentation BEFORE my appointment is confirmed.


I understand intake documentation must be completed 24 hours before my appointment.


I understand that there is a 24 hour cancelation police. Within the 24 hour window, appointments will not be refunded.


I understand I will be charged at the time of booking.

Yes, I understand!

"I understand this appointment does

not guarantee medication will be prescribed."

Yes, I understand!

"I am not seeking emergency care.

Proactive Psychiatry does not provide emergency care for suicidal or homicidal ideation, mania, hypomania, catatonia,

or any emergent condition."

Yes, I understand!

If you need emergency care

please go to the nearest emergency room

or call 911.

In what state are you located?
Washington DC
Maryland
New York
Colorado
Virginia
Other

Where did you hear

about Proactive Psychiatry?

Referral
Psychology Today
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Other
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