Please take a few minutes to provide us with information so we can help you. If you would like to speak directly to a Clinician, please call us now at (866) 606 - 4233.

Fill out your contact details and give us as much information about your family member's difficulties as possible. Our Medical Director and his clinical staff review this information to understand your concerns to better help you. They will then contact you with personalized information about how The Drake Institute can help you or your child within 24 hours.
We value your privacy!

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Your First Name:  * You will have a chance to enter information about the friend / family member who may be experiencing symptoms, on the next page.
Your Last Name:  *
Your Gender:
Street Address: * Apt / Suite:
City: * State:  / Zip:  *  / 
Email: *
We have accelerated 6 to 8 week treatment programs for patients who do not live in Southern California. I would like a telephone consultation about coming to Southern California for the accelerated program.
What is the best time to reach you? area code number ext
What is the best number to reach you? *
Is there another number to reach you? 
On the next page you may enter information for up to two patients. In order to serve you better, please fill out a little information about the most concerning patient below. The more information you can provide, the better we can assist you.
How old is the patient?*
Have They been Diagnosed with an Attentional, Emotional, Learning, Autism Spectrum or Stress Disorder? *
If the patient is on Medications, are you happy with the Medications?*
Are you looking for help right now? *
How did you discover the Drake Institute? * If Other:
Click to move on to the Symptoms Checklist