Request an Appointment | Making Waves Mental Wellness LLC

Your Healing Journey Begins Today

Please complete the form below to get started

Patient's First Name

Patient's Last name

Patient's (or Parent's) Phone

Must be the patient's phone number if 18 or older

Patient's (or Parent's) Email

Must be the patient's email if 18 or older

Patient's Birthday

Month

Day

Year

Relationship to patient (If patient is 18+ they must complete/consent)

Relation to patient

Insurance/Self-Pay

If "Other" please list below

Other

My Phone (if different from the patient's)

What brings you to Making Waves?

Please list previous psychiatric diagnoses. If none, please enter N/A

Please list any current medications and dosages. If none, please enter N/A.

Have you ever been admitted to a mental health hospital for more than 48 hours?

If yes, please list the month and year of each hospitalization.

Have you ever been prescribed a controlled substance? (Benzodiazepines, Stimulants for ADHD, Hypnotics/Ambien, Ketamine, etc.)

If yes, list medications below

How did you find us?

We are not a crisis/rehab/detox center. If you are having a mental health crisis (active suicidal thoughts/plans, auditory and/or visual hallucinations, detoxing/withdrawing from substances) please call 911 or visit your nearest emergency department.

Consent

By submitting this form, you are providing consent for the submission of this form to a HIPAA compliant secured email storage, understand this website host does not store personal information, and Making Waves Mental Wellness, LLC to reach out to you via one of the contact methods listed above, as well as allowing access and review of your medication history as part of our commitment to delivering personalized and comprehensive mental health care.