New Client Request Form
For assisting in matching you to the best clinician to meet your needs. We will contact you regarding your request in the next 24 to 48 hours.
This is not intended to be used for emergencies- if you are experiencing a medical or psychiatric emergency, please go to the hospital or call 911.
Name (of person seeking treatment)
If the potential client is a minor, who is the best contact person and their relationship to the child?
**If under 18** Is there a custody agreement in place for the minor? (If so, we will need a copy of this so we can best accommodate your family's needs)
There will be, but not yet
Not under 18
Your email address (by giving your email, you're stating you are comfortable with receiving emails from an address ending in @
Date of Birth
Reason for seeking treatment
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