Request an Appointment

Use this secure form to request an appointment with Inspired Consciousness LLC. This form is for scheduling requests only. It is not for emergencies, crisis support, medication changes, clinical advice, or urgent symptoms.

Please do not include detailed symptoms, diagnoses, medication lists, prescription images, or clinical notes in this appointment request. If you become a patient, clinical information will be collected through approved clinical workflows.

Emergency and Crisis Support

This appointment request form is not monitored for emergencies, crisis support, medication changes, urgent symptoms, or immediate safety concerns.

If there is immediate danger, call 911 or local emergency services.

In the United States, call or text 988 for mental health, substance-use, or emotional distress crisis support.

Important Portal Notice

This appointment request form is used to request scheduling only. It does not establish a provider-patient relationship, confirm acceptance as a patient, provide medical advice, provide psychotherapy, provide medication management, authorize prescription changes, or provide emergency support.

Please do not include detailed symptoms, diagnoses, medication lists, prescription images, clinical notes, or urgent concerns in this form.

A member of the scheduling team will review the request and contact you. An appointment is not confirmed until the clinic confirms it directly.

Privacy Notice

This appointment request form collects protected health information for scheduling and care-coordination purposes. Information submitted through this form is stored in a secure, access-controlled system and may be reviewed by authorized workforce members for scheduling and clinical intake coordination.

Please review the Notice of Privacy Practices before submitting this request.

View Notice of Privacy Practices →

1. Choose preferred provider

Preferred provider *

I am open to an alternative provider if my preferred provider is not available.

2. Days and times you are available

Select the days and times when you are generally available for appointments. This does not confirm an appointment—our scheduling team will contact you to finalize.

3. Contact information

Legal first name *

Legal last name *

Preferred name (optional)

Date of birth *

Email *

Phone *

Preferred contact method *

State where you will be located during telehealth services *Telehealth services require the provider to be licensed in the state where you are located at the time of the appointment.

4. Privacy, safety, and consent

I understand this form is not for emergencies, crisis support, urgent symptoms, medication changes, or clinical advice. *

I will not include detailed symptoms, diagnoses, medication lists, prescription images, or clinical notes in this scheduling request. *

I have been provided access to the Notice of Privacy Practices. *

I consent to being contacted for scheduling and appointment coordination using the contact information I provided. *

I understand that telehealth may have technology, privacy, emergency-response, and state-location limitations, and that full clinical consent may be completed before services begin. *