New Patient Inquiry.

Complete this form to request an initial appointment, or to learn more about our Services. It may be helpful to review Billing & Insurance information in our Practice Policies prior to requesting an appointment.

Existing Patients: Book an Appointment directly online.

Name

First Name

Last Name

SERVICES REQUESTED (select all that apply)

Individual Therapy

Psychiatry (Evaluations, Medication Management)

Mobile Phone

(###)

###

####

Client Date of Birth

Needed only if scheduling appointment

YYYY

Message

Please briefly describe what services you are looking for, and indicate if you would like to schedule an appointment. Listing your preference for days of the week (M-F) and morning or afternoon appointments is helpful, and we will do our best to facilitate your schedule.

Acknowledgment

I understand that The Stratford Clinic do not take insurance, but may provide superbills upon request.

I have reviewed The Stratford Clinic's Practice Policies.

Select Provider

How Would You Like to See Your Provider?

Online submissions can help facilitate scheduling by connecting you to the right clinician. Please confirm you understand the following about these communications:

I understand that website submissions are not considered secure communications. I consent to The Stratford Clinic using the information I have provided for purposes as outlined in The Stratford Clinic's Privacy Policy.

New Patient Inquiry.

Thank you for reaching out. A member of our team will be reaching out to confirm your appointment or answer other questions you may have. Please review our Practice Policies for any additional questions.

The Stratford Clinic