New Patient Form

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New Patient Form

Please fill out this form to help us determine if Dr. Gelbart can provide the level of care you need. If he would be a good fit, you will be emailed with more information about setting up an evaluation.

For more information about Dr. Gelbart, his psychiatric practice, and other new patient information, please visit: www.thepotentmind.com

Note: Form & submission is HIPAA compliant according to Google Workspace HIPAA compliance standards.

Email *

How did you hear about Dr. Gelbart? *

If you were referred by another professional, who was it/what was the name of the organization?

What types of services is the patient looking for? (Select all that apply) *

Medication management

Psychotherapy

Life Coaching

Required

Please provide a brief paragraph about why your seeking services. *

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