New Client Intake Form
We are accepting new Clients! Please use the form below to inquire about therapy services. Completing this form does not guarantee availability or appointments. We can provide other resources to call if we are unable to meet your needs at this time.

 If this is an urgent, life-threatening issue call 911, go to a local hospital, or call your local crisis line.

DISCLAIMER: The contact form below is not HIPAA compliant. Please only send your basic contact information and we can discuss your needs in more detail over the phone.
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Name *
Email *
Phone *
Contacting About *
Required
Insurance or Self Pay (Note; The insurances listed are the only ones we accept)  *
Required
Preferred Therapist (if that therapist is full we will offer another therapist in our practice or send you a list of referrals).  *
Required
Age range of prospective client *
Required
Who is referring you/How did you hear about us?  *
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