Consultation Form

Client's Name

Client/ Guardian Phone Number *

Client's Date of Birth *

MM

/

DD

/

YYYY

Client's Gender *

Male

Female

Prefer not to say

Other:

Please give a brief description of why you are seeking services. *

Do you have a history of substance abuse? *

Yes

No

Do you have a history of self harming behavior or suicidal ideation? *

Yes

No

I am in-network with Cigna, Optum, Oxford, United Health Care, Aetna, and Oscar Health. Please select how you will be paying for services. *

Insurance

Self Pay

How would you like me to contact you? *

Phone Call

Email