To access the MYIO/Valant patient portal, please follow the link below:

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MYIO/Valant portal link:

https://valant.io/myio/ModernMentality

INTAKE REQUEST FORM

The first step to become a patient at Modern Mentality is completing this form. This information is intended to assist in coordinating an initial appointment and evaluation.

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I am

over age 18 and seeking care for myself
a parent or guardianactingon behalfof a minor

Name *

First

Last

Sex and gender

Email *

Date of Birth *

Phone Number *

Single Line Text

Street Address

Street Address Line 2

City

Postal / Zip Code

State / Province

How do you plan to pay for services ?

Insurance
Private pay

If using insurance, enter your plan, and group number below *

How did you find our practice? *

Why are you seeking psychiatric care? *

Are you having suicidal thoughts?

Have you ever been hospital for psychiatric reasons? if so, when and for what reason ? *

Please list current medications and medical concerns: *

What times and dates are you best available for appointments? *

Any additional details you would like to share? *

If you are currently experiencing suicidal thoughts or a life-threatening emergency, please contact 911, 988, or present to your nearest emergency room. You can also contact the Massachusetts Behavioral Health Helpline at 833-773-2445 or the New Hampshire Rapid Response Access Point at 833-710-6477, depending on the state you're in. Please note that this contact form is not monitored in real-time.

Get Started Today!

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Name *

Email *

Phone Number *

How did you find our practice? *

Message / Comments *

Prove You Are Human: *