Full Name
*
Email
*
Do you agree to receive email newsletters from East Coast Mental Wellness?
YES
NO
Phone
Opt In Consent
(OPTIONAL) I would like to opt-in to receive text messages from East Coast Mental Wellness regarding appointments, reminders, and important updates. Message frequency varies. Message and data rates may apply. For help and support call 401-227-0372 or email
[email protected]
. I can reply STOP to opt-out of texting at any time. For more information visit our Privacy Policy and Terms and Conditions, both are available at https://www.eastcoastmentalwellness.com/privacy-policy-and-messaging-practices/.
Brief description of the issues you would like to address in therapy.
*
What insurance do you have?
*
How did you hear about us?
Facebook/Instagram
Google Search
Friend/Family
Referred by insurance
Others
Privacy Policy Agreement
I acknowledge that I have read and agree to the Privacy Policy of East Coast Mental Wellness. I understand how my personal information will be used and protected.
Submit