Request an Assessment

Reaching out is the first step. Whether it's for yourself or someone you care about, share a few details below and our team will contact you directly. No account or sign-in is required.

Personal Details

Full Name *

Phone Number *

Email (optional)

Age (optional)

Gender (optional)

Emergency Contact / Next of Kin (optional)

Full Name

Phone Number

Relationship

Reason for Seeking Treatment

What's going on? *

Health Background (optional)

Brief Medical & Mental Health History

Current Medications

Known Allergies

Substance Use History (if applicable)

Alcohol Khat / Miraa Cannabis Opioids Prescription Drugs Stimulants Inhalants Other

A Few Last Details

Urgency

Best time to reach you (optional)

Already a registered patient? Sign in to your portal instead.

Request an Assessment

Request received