top of page

New Patient Registration 

Click for .pdf Version

Fastest way - fill out below and submit:

New Patient Form

Partner with Sea Glass

We collaborate with primary care, health care specialties, social workers, counselors, schools, colleges, and more to ensure maximal outcomes in patient care.  Our goal is to work with co-treating professionals, not in competition.

If you have a client or student that could benefit from psychiatric intervention and possible medication management from caring local providers, please fill out the form below and we are happy to help provide attentive, individualize care.

​

Click here for the referral form and fax to:  800-859-7958 

Or email .pdf to:  office@seaglassct.com 

We accept CT Medicaid (Husky), Medicare, and most commercial insurance plans.​​

Refer a client to Sea Glass
Referrals From Other Providers/Schools
List of Common Forms

As of January 1, 2022, under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.​Under the "No Surprises Act", You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

Green Watercolor Texture

Mailing Address

515 Centerpoint Drive

Suite #901 

Middletown, CT 06457

Phone

Phone: 203.990.2555

Office Staff available Mon- Fri

8:00 am to 4:30 pm

Fax800-859-7958

Email

office@seaglassct.com

For general inquiries or to send forms only, not for clinical questions or patient enrollment

Connect

  • Tik Tok
  • Facebook
  • Instagram
bottom of page