New Client Registration
If you are interested in becoming a new patient please submit the following form to our office to begin the process. It is our desire to ensure a proper fit between our practitioners and you; the following information will help us in doing so. Please be aware that there are limitations on who can be seen in our office. Requests for new patient consultations are reviewed and may take a few days to process during our busy periods. We ask that you please be patient and do not submit multiple requests as this will only delay our efforts to make appropriate contact with all of those waiting.
**This form is encrypted and stored in a HIPAA compliant database.**
**This form takes 5-10 minutes to complete. You will need your insurance information and a payment method.
Your first and last name *
(William Gates)
Your answer
Email address *
Your answer
Primary Contact Phone *
Your answer
Secondary Phone
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Patient's name *
Your answer
Gender *
Your answer
Date of Birth (mo/day/year) *
Your answer
Current age *
Your answer
What is the name of your current therapist? *
Your answer
How did you hear about us? *
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