New Patient
Appointment
Request

Please complete the form to start your journey here with us at Monarch Mental Health and Wellness.

First Name

Last Name

Full Address

Phone Number

Date of Birth required

Email Address

Member ID Number

What are you looking for? (check all that apply)

Medication Management

Therapy

How Did You Hear About Us?

Briefly Describe Your Reason of Visit:

By submitting this New Patient Appointment Request Form, you agree to have Monarch Mental Health and Wellness contact you by our HIPAA compliant text/phone line or by email.

YES! I agree to receive text messages from Monarch Mental Health and Wellness sent from our HIPAA compliant line 804-223-3165.

NO. I do not agree to receive text messages from Monarch Mental Health and Wellness.

Thank you for submitting a New Patient Appointment Request!
We’re excited to be part of your wellness journey and look forward to supporting you every step of the way. Our team will be in touch with the next steps. In the meantime, if you have any questions, feel free to visit our FAQs to learn more about our Intake and Onboarding Process.

Please complete the form below and we will be in touch with next steps! You may also check out our "Intake / Onboarding Process" in FAQs.

New Patient Appointment Request: