Name *

First Name

Last Name

Phone *

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What services are you interested in?

Talk Therapy

Psychiatric Medication

Child & Adolescent Psychiatry

Psychiatry for Adults

Psychotropic testing

ADHD Treatment

Spravato (esketamine)

Preferred Visit Type

Please let us know how you'd prefer to attend appointments. This helps us match you or your child with the right provider.

In-Person

Telehealth

Either works

Prefered Contact Method

No Preference

Call

Text

Email

SMS Opt-in

Please check the box below if you would like to receive SMS text messages from Nebraska Peace of Mind Behavioral Health, LLC for appointment reminders, confirmations, and other important updates related to your care. By checking this box, you agree to receive text messages at the phone number provided. Standard messaging and data rates may apply. You can opt out at any time by replying "STOP" to any message or contacting us directly. I agree to receive SMS text messages for appointment reminders and updates. Note: This opt-in is not required to receive services, and you may still receive communications via email or phone.

Agree