New Patient Request
.:Intake request form to be matched with an Anchor Clinic clinician:.
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Email *
Full Name *
Date of Birth *
MM
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DD
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Phone Number *
Mailing Address (Please include street, city, state, and zip code) *
Are you interested in telehealth services at this time? *
Please provide a general description of what you are currently struggling with. Any information shared here will only be available to the clinic staff as well as yourself (and anyone with access to your email should you request a copy of your responses today). *
What days and times would work best for your sessions? Choose all that apply. *
Required
Do you currently have insurance with mental health coverage? If yes, please provide the type of insurance that you currently have. Insurance is NOT required to be considered for an intake. *
Are you interested in messaging based therapy plans (private pay only at this time)?   *
Is there a specific clinician you are interested in working with? Please check all options that apply. *
Required
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