If you'd like us to reach out via phone (including SMS)
Requests involving protected health information require verification before any response.
(Care and coverage work a little differently in each state)
What's the email address associated with your Cerebral account?
@cerebral.com emails only
URLs only
This is the email address we will use to contact you about your request
Enter the name of the Cerebral client you're inquiring about
Enter the DOB of the client you're inquiring about (MM-DD-YYYY)
Please attach below
for my therapist or prescriber
Pharmacy phone number
Attach your authorization or legal documentation below
Include anything else you'd like us to know or enter "N/A"