Request Form for Psychiatry Services

Please submit your information here for our staff to review.
If Dr. Thomas is deemed a good fit for your needs, our office will be in touch to schedule an intake appointment.

 

 
Name 
*
Phone 
*
Email 
*
Are you/referred patient 15 or over?
Have you seen Dr. Thomas before?
Do you currently have a psychiatrist or medication prescriber?
Reason for appointment request (please provide details regarding your appointment request) 
*
COVID-19 Update:
Practicing social distancing is the most responsible behavior in which we can all engage at this time. For the utmost health of you, us, and our families, Fresh Start for the Mind is conducting the majority of our services via VIDEO TELEHEALTH. Our administrative team will be happy to assist you with setting up a new or recurring appointment. We are also honored to offer Crisis Counseling to local medical staff and other front-line workers. Click here for more information.