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New Client Interest Form
Please complete this form and submit. We will contact you soon with information about the services that interest you. All responses are stored in a HIPAA complaint manner to ensure confidentiality.
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Preferred Name:
Your answer
Full Legal Name:
*
Your answer
E-mail address:
*
Your answer
Phone number:
*
Your answer
Preferred Method of Initial Contact
*
Phone call
Text message
Email
Required
Date of Birth (MM/DD/YYYY):
*
MM
/
DD
/
YYYY
I identify as (Gender & Pronouns):
*
Your answer
I would like more information about:
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Adult Psychological Evaluation
Child Psychological Evaluation
Adult Therapy
Child Therapy
Emotional Support Animal Assessment and Letter
Required
Please indicate your preferred payment method:
*
Insurance
Card payment
If insurance is selected above, please indicate insurance type (Medicaid, United Healthcare, BCBS, etc.):
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Please briefly describe what brings you to seek services at this time:
*
Your answer
Please share information regarding your current mental health treatment team (e.g., therapist, psychiatrist, life coach, nurse practitioner, etc.):
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Your answer
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