Empower - Change - Live Well
(860)-946-0447
[email protected]
Home
Clinical Team
Our Services
HHS Therapeutic Treatments
Neuropsychological Testing
Groups & Classes
Payment & Fees
Contact Us
Sign Up to Our Mailing List
Appointment Request
Glastonbury Location
West Hartford Location
Media
Blog
Appointment Request
Please complete the form below to schedule an appointment. We will try our best to accommodate your request and will be in touch ASAP.
First Name
*
Last Name
Email
*
Phone
*
What Type of Appointment Is This?
*
New Appointment
Follow Up Appointment
Doctor's Referral
What Health Issues Are You Experiencing?
*
Additional Comments
New Clients Only
New Clients Only
Client's Date of Birth
Date Format: MM slash DD slash YYYY
Client's Insurance Company
Policy Holder Name & DOB (if different than client)
Address Information
Street Address
Address Line 2
City
State / Province
ZIP / Postal Code
Comments
This field is for validation purposes and should be left unchanged.
