New Clients

Client's Name *

First

Last

Date of Birth *

Client's Age (We only work with adults who have no legal guardian.) *18-21 years22-41 years42-61 years62+ years

Client's Pronouns *

Email *

Phone Number *

May We Leave a Voicemail?YesNo

How did you find us? *Therapist referralFacebookLinkedInPsychology TodayGoogle/internet searchOther

If a therapist or another provider provider referred you, what is their name? *

Service(s) Requested

• Medication Management/Psychiatry (insurance or cash pay)
• Autism Assessment (cash pay only)
• Psychotherapy/Talk Therapy (insurance or cash pay)

Briefly describe any mental health or substance abuse concerns *

Please list any medical conditions and significant past medical history below, such as Diabetes, Asthma, Hypertension, etc. *

Current Medications or Supplements and Doses (if not on medication, write none) *

What health insurance do you have? (Note: we CANNOT accept clients who have Medicaid or Medicare as primary or secondary plans) *

After review of this form, a member of our team will call you on the phone for a required screening to collect necessary information. This call may take 3-5 minutes and is required prior to scheduling your video or in-person appointment. Please allow 3-5 business days to receive a response. The submission of this form does not establish a provider-client relationship. Please check the box below to acknowledge the statement. Thank you. *

• I acknowledge that I have read, understood, and answered the information to the best of my knowledge.

PLEASE NOTE: DUE TO THE HOLIDAYS, NO NEW CLIENT REQUESTS WILL BE PROCESSED UNTIL AFTER JANUARY 10TH, 2025. YOU WILL HEAR BACK FROM US WITHIN A FEW DAYS AFTER THAT.

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