Quietside Psychiatry | SimplePractice

Your info

First name

Last name

Phone

Do you live in the state of Maine?

Yes No

Are you 18 or older?

Yes No

Important: This practice provides outpatient telepsychiatry only and does not provide crisis or emergency services. If you are experiencing suicidal thoughts, feel unsafe, or are at risk of harming yourself or others, please do not complete this form. Call 911, go to the nearest emergency department, or call/text 988 for immediate support.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.