New Clients Please enable JavaScript in your browser to complete this form.Client's Name *FirstLastDate of Birth *Client's Age (We only work with adults who have no legal guardian.) *18-21 years22-41 years42-61 years62+ yearsClient's Pronouns *Email *Phone Number *May We Leave a Voicemail?YesNoDo you have a provider preference?Carolyn Mallon, APRN (med management)Jennifer Maynard, APRN (med management)Aslynn Romano, APRN (med management)Aslynn Romano, APRN (autism assessment)Samuel Sobel, LICSW (therapy)Nikki Dinwiddie, LICSW (therapy)Who Referred you?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 do NOT accept Medicaid or Medicare plans) *The submission of this form does not establish a provider-client relationship. After review, our assistant will call you with the available appointment times or to discuss further. Due to the volume of requests please allow 2-3 business days to receive a response. 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.Submit