David Buckley, PMHNP | SimplePractice

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Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Depression Other

What kind of care is being sought?

Psychotherapy Medication Other Not sure

Current/Past Mental Health Treatment? (please specify current/past medications, if any)

[i.e. current/prior therapy, medications, hospitalizations and diagnoses/reasons for treatment]

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Administrative

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Billing & Payment

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Client Preferences

Preferred day/time for initial consultation call (15-30 min, no charge, Tuesdays or Fridays 11am-6pm ET only)

[i.e. Tuesday 5pm-6pm, Friday 11:30am-1:30pm, etc.]

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.