If your request is urgent, please call our office at (855) 436-7792 to request an appointment today.

Please fill out the form to request an appointment. We will be in contact with you shortly. Please contact info@genpsych.com if you have questions filling out the form.


Appointment Location (required)

Your Name (required)

Age (required)

Date of Birth (required)

Your Email (required)

Your Phone Number (required)


Type of Insurance

Have you ever been to GenPsych for treatment before?

If yes, time and reason for visit:

Do you have any history of seeing a psychiatrist?

If yes, date of last visit:

Please list any medications you currently take:

Do you have any history of seeing a therapist?

If yes, date of last visit:

Do you experience any symptoms of depression, anxiety, panic attacks, self-harming thoughts? (please list all that apply)

How long have you had these symptoms?

Do your symptoms interfere with your ability to go to work or school daily?

Have you recently visited an emergency room or hospital due to mental health symptoms?

If yes, date of visit: