Provider Referral

Thank you for allowing us to assist in the care of your patient.
Please either fill out the secure form below or download the form here, print, and fax to (212) 717-4872.

Patient Information
Name*
Date*
MM slash DD slash YYYY
Primary Diagnosis
Provider Information
Referring Provider*
Provider's Specialty*
Provider's Address*
Street Address Address Line 2 City State ZIP Code
Provider's Email*
Provider's Phone*
Provider's Fax
Reason For Referral*
Comments
This field is for validation purposes and should be left unchanged.

Getting Started is Simple

We welcome all prospective patients to contact us and take the first step on the road to wellness by learning more about TMS and Ketamine Therapy and how they can help you find relief.

Check out our FAQ and Resources to learn more about what we do and how TMS or Ketamine Therapy may help you.
Call us to set up a consultation at (315) 757-3735 about outpatient therapy for depression or another condition, or fill out the Contact Us Form below. You may also ask your physician, therapist, or psychiatrist to fill out our Provider Referral Form and we will be happy to work with them throughout your treatment process.
We will contact you to discuss your symptoms, medical history, and prior therapies, as well as answer any additional questions you may have about our process and treatment options and schedule an in-office consultation.

Patient Information

Provider Information

WHERE CONVENIENCE AND COMFORT MEET INNOVATION IN A MODERN CLINIC SETTING

Getting Started is Simple

We welcome all prospective patients to contact us and take the first step on the road to wellness by learning more about TMS and Ketamine Therapy and how they can help you find relief.

Send Us A Secure Email

Services

About Us

Resources

Contact Us

Patient Information

Provider Information

WHERE CONVENIENCE AND COMFORT MEET INNOVATION IN A MODERN CLINIC SETTING

Getting Started is Simple

We welcome all prospective patients to contact us and take the first step on the road to wellness by learning more about TMS and Ketamine Therapy and how they can help you find relief.

Send Us A Secure Email

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