New Patient Form

New Patient Request for Treatment

* Indicates required field

New Client Name *

First

Last

New Client Phone Number *

New Client Age *

If New Client is 17 years old or younger, please provide Name and Contact Info of New Client's parent or guardian

Parent/Guardian Name *

Tell us how we can help? *

New Client Email *

Parent/Guardian Phone Number or Email *

Please feel free to tell us anything else you think might be helpful *

Please note, psychiatrists currently have up to 12 months waitlists and require a referral from your GP. If you have any questions, please email the clinic at admin@threestoryclinic.com

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