This form helps prospective patients/clients and clinicians connect more efficiently and explore whether the requested relationship will be a good fit. As clinician skill sets, availability, and financial policies vary, this form helps ensure you find the right clinician for your needs.

If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911 or go to your closest emergency room.

This request is not an emergency or urgent matter. I wish to proceed
Is patient is an adult (18+ years old) or a minor (under age 18)
Are you taking Xanax daily or expect to take xanax daily?
Dr. Tariq doesn't prescribe Xanax to be taken on a daily basis. Are you willing to decrease your use of Xanax?
Are you seeking help to get a disability or leave of absence form filled out? Please understand that Dr. Tariq doesn't fill out disability forms, or leave of absence forms.

Unfortunately, it seems like our practice will not be a good match for your needs. It would be best if you seek care from a different provider. It will help prevent any hard feelings down the road.

Request Appointment