Intake Form
* Please complete and submit the information below and we will contact you and connect you with one of our therapists.
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Office Location *
Are you available to meet with a therapist during the day (ie: 9am-3pm)? *
Client's Last Name *
Client's First Name *
Insurance Subscriber's Full Name *
Medicare Beneficiary ID (If Medicare is your primary insurance)
Client's Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Email Address *
If the client is a minor and the child's parents are divorced with joint-custody, please list additional contact information below (phone & email of 2nd parent) so both parents can complete initial intake forms. (Please put N/A if not applicable) *
Referred By *
Therapist requested - please keep in mind that this does not guarantee that this therapist is accepting new clients.
Insurance *
Member ID *
Reason for Seeking Counseling Services *
Are you still interested in services if telehealth (video/phone) sessions are the only option at this time? *
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