Contact Us

Request an Evaluation

If you are a new patient seeking evaluation please start with this form.

We will be in contact with you within 1-2 business days.

Initial Agreements

By checking this box I agree that this request is not an emergency or an urgent matter. If this is a medical emergency, or you feel that you are at imminent risk of hurting yourself or others, please call 911 or head to the Emergency Room for treatment. The level of care provided by this clinic may not be able to meet your needs in this moment.

By checking this box I acknowledge that this clinic does not have in-person appointments, and am comfortable with participating in virtual appointments requiring microphone and video access.

By checking this box I acknowledge that this clinic does not prescribe controlled substances. A full list of what is considered a controlled substance can be found under "Our Services" or in the FAQ.

Patient Information

First Name

Last Name

Date of Birth

Phone

Address

Clinical Information

What kind of care are you looking for?

Medication

Psychotherapy (availability varies depending on caseload. Referrals can be provided if needed)

Not sure

Other (describe below)

What brings you in today?

Do you have any limitations with regards to scheduling appointments?

Identification

Please provide proof of identification and copies of insurance cards if you have them.

Images can also be emailed to admin@desertblossompsychiatry.com if any issues arise

Identification

Upload supported file (Max 15MB)

Insurance Card (Front)

Upload supported file (Max 15MB)

Insurance card (Back)

Upload supported file (Max 15MB)

Referrals

How did you hear about us?

From a friend

Business card/advertisement

Online search

Doctor's Office

Psychology Today

Insurance

Other

Thank you for reaching out to us! Our staff will reach out to you soon. Please check your spam or junk email folder if you do not recieve a response within 1-2 business days.

Work with Us

If you are a therapist, psychologist, or other healthcare professional please use the form below.

We welcome collaborations within the community in order to provide the best care possible.

First Name

Last Name

Phone Number

Leave us a message...

Thank you for reaching out to us! We will be in touch soon.

Desert Blossom Psychiatry

admin@desertblossompsychiatry.com

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