Welcome to Psycle!

We are excited to welcome you as a partner in our mission to democratize innovative treatment methods.

Please set aside at least 5 minutes to complete this form, and remember that the sooner we receive submission of your clinic's information, the sooner we will be able to generate new patient evaluations.
Please complete this form on a desktop or laptop.
Any confidential information shared via this form will be used solely for the purpose of evaluation generation for your clinic.

Are you a Clinic Owner, Manager, or Director?

Yes

The following questions pertain to your contact information.

First Name

Last Name

Title

Phone Number

The following questions pertain to the Clinic Owner or Manager (whoever is more actively involved in the clinic's development).

Owner/Manger First Name *

Owner/Manger Last Name *

Owner/Manager Title *

Owner/Manager Email *

Owner/Manger Phone *

The following questions pertain to your clinic's listing information. We will match individuals to your clinic based on this information.

Clinic Name *

Clinic Email *

Clinic Phone Number *

Clinic Fax #

Clinic Address *

Clinic City *

Clinic State *

Clinic Postal Code *

What services does your clinic offer? *

Clinic Website URL *

Clinic EMR *

Insurance that clinic accepts if any *

Thank you for submitting your form!

Please be sure to select submit below. We will reach out to you shortly to discuss next steps and start generating evaluations for your clinic!