Request a Consultation

Whether you are seeking support for anxiety, depression, trauma, mood disorders, life transitions, or personal growth, Mind Bridge Wellness is committed to providing a safe, inclusive, and empowering space where healing can begin.

New Patient Inquiry

First Name:(Required)

Last Name:(Required)

Birthday:(Required)

Phone:(Required)

Email:(Required)

Do you live in New York State?(Required)

How do you plan to pay for services?(Required)

If using insurance, please list your provider (N/A for self-pay):

Please briefly describe what you are seeking help for:

Have you been diagnosed with any mental health conditions and/or received mental health treatment in the past?(Required)

If yes, what treatment have you received (therapist, psychiatric prescriber, etc.) and when? If not, please enter "N/A":(Required)

Have you ever been hospitalized in a Behavioral Health facility?(Required)

When and where have you been hospitalized?(Required)

Are you currently taking any psychiatric medications?(Required)

If yes, please list the medications below:(Required)

Do you have any current thoughts to hurt yourself?(Required)

Are you currently, or have you ever been, law enforcement/first responder, including volunteer EMS or Fire Dept?

Are you active or retired military?(Required)

Do you have anyone in your family that is a current or retired first responder or military?(Required)

What is the relationship?(Required)

How soon are you hoping to being treatment?(Required)

As soon as possible

Within a few weeks

Within the next couple of months

How did you hear about us?(Required)

Internet Search

Referral from a provider

Friend or Family

Psychology Today

Other

Please specify other:(Required)

Is there anything else you would like us to know?