Please only complete this form if you are suffering from undiagnosed anxiety and do not have any other diagnosed health conditions listed. If you are not certified for health reasons, we issue a full refund.

All new patients must register at the PADOH and create a patient registration account. If you’re having trouble with that, we are happy to take care of that step for you. You can find a link to the state’s website for patients in the services tab above.

If you’re ready to go, please complete the following: