Once submission successful, a confirmation notice will appear.

If the form did not submit, then you are missing information above.

A team member will review your request and contact you to schedule your appointment with our provider. Given the many choices available, we appreciate you choosing our facility as a destination for your mental health care.

If you are having technical difficulties utilizing our online submission process, then you can instead download the PDF form below. Please fill it out completely and email back to us.

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FAX: (480) 454-1085


4001 E Baseline Rd Ste 204

Gilbert, AZ 85234