WEB New Patient - Gateway to Wellbeing Clinic

The completed form will be emailed to a clinician at Gateway. As with all electronic communications, email is inherently insecure. If you want to guarantee the security of your message, please install a secure email service, like Virtru, and email our office manager directly at hershe@gatewaypsychiatric.com.

Please fill out the form below and we will be in touch shortly. *This question is required.

First Name *This question is required.

Last Name *This question is required.

City

Email Address *This question is required.

Phone Number *This question is required.

How did you find out about us?

How do you prefer to be contacted? Email is often faster.

Name of professional

Name of other referral

Other source

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