NEW PATIENT INQUIRY

Patient's First and Last Name

Parent's Full Name (if patient is a minor)

Patient's Email (This will be used to receive communication from Dr. Hoffman- Be sure to check your spam folder)

Patient's Phone Number (This will be used to receive communication from Dr. Hoffman):

Is the patient currently suicidal or experiencing a mental health crisis

How did you hear about me? Please list referral source.

Are you needing assistance with any legal or custody matters?

Ashley Hoffman, Psy.D.