Phone: 207-560-3770
Fax: 207-560-3128

First Name

Last Name

Phone

Email

Briefly, why are you seeking care at this time?

Please list any psychiatric medications you are currently taking:

Have you been psychiatrically hospitalized in the last 12 months? *

No

Yes

Are you suffering from an active addiction to alcohol or drugs? *

No

Yes

Office hours are Tuesday to Friday. Best efforts will be made to respond to inquiriess within one business day.

Thanks for submitting!

Contact:

To make a referral or request information please call or fax:

Mark Shaughnessy PMHNP

15 Pleasant Hill Road, Suite 204

Scarborough, ME, 04074

Phone: 207-560-3770 Fax: 207-560-3128

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