First Name *

Last Name *

Email Address *

Mobile Phone Number *

Preferred Service *
Individual PsychotherapyPsychiatric EvaluationMedication ManagementMental Health EvaluationImmigration Mental Health EvaluationOther / Not Sure

Preferred Appointment Type
TelehealthIn-PersonNo Preference

Preferred Day/Time

SMS Communication Consent

I agree to receive SMS text messages from Good Shepherd Psychiatric & Medical Center (GSP Medical Center).

By checking this box, I consent to receive customer care and account notification messages, including appointment scheduling, appointment reminders, confirmations, rescheduling or cancellation notices, and responses to customer service inquiries.

Message frequency varies. Message and data rates may apply. Reply STOP to opt out at any time. Reply HELP for assistance. Consent to receive SMS messages is not a condition of purchasing or receiving services.

Privacy & SMS Messaging Policy | Terms & Conditions

Important

Please do not include sensitive medical or mental health information in this appointment request.

Submitting this form does not establish a therapist-client or provider-patient relationship and does not guarantee an appointment.

This form is not for emergencies. If you are experiencing a medical or mental health emergency, call 911 or go to the nearest emergency department. For suicide or mental health crisis support in the United States, call or text 988.