Intake Form
Your First Name *
Your Last Name *
Email
Phone number *
What type of support are you seeking? *
For whom are you seeking support? *
If you will not be the client, please give us their first and last names.
How can we support you/your family? (Why are you seeking treatment?) *
Required
Availability: Which days and times are best for appointments? *
8am-12pm
12pm-5pm
5pm-8pm
Not Available
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
Clinician Preference *
If you have a gender, age, sexual orientation, modality or specialty preference please list below. If you do not have a preference please state "no preference."
Do you plan to use insurance for treatment? *
Insurance Coverage *
If you would like to partially pay 'out of pocket' for treatment please select your insurer and "I will pay out of pocket."
Required
How did you hear about us? *
Is there anything additional that you want us to know?
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