JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
New Patient Inquiry
Synergy Psych seeks to create exceptional patient experiences, and that begins by determining if we are a good fit for your needs. Please share more with us and know that we will follow up to help.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
I am most interested in the following services:
*
Psychiatric evaluation to determine if I need and/or can benefit from medications.
Recovery-friendly Psychiatry
Psychiatric evaluation to help me re-evaluate my current medications and determine if I need something different.
Transfer of medication management from another psychiatric provider
Transfer of medication management from my primary care physician
Medication-assisted Treatment for addiction
Evaluation to learn what services I need to feel better & experience more function & joy in my life.
Other:
Required
Have you ever received any or all of those services from another provider?
Yes
No
I"m not sure.
Clear selection
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Full Life Counseling.
Report Abuse
Forms
