Intake Form-Appointment request

Intake Form

Completing this form will shorten the registration process, all data is HIPPA regulated and secured.

Legal Name

First Name

Last Name

List current Medications

DOB

Dates of Psychiatric Hospitalization

Name of Health Insurance

First and last name of insurance Policy Holder

Are you currently seeing a therapist?

Yes

Searching

Unwilling

What would you like to share about yourself?

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

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