/new-client

Personal Information

Basic details to help us create your client profile securely.

First Name *

Last Name *

Date of Birth *

Pronouns

Emergency Contact Name *

Relationship

Emergency Phone *

How we can reach you and billing preferences.

Email Address *

Primary Phone *

Insurance Provider

Policy Number

Preferred Contact Method

Help us understand your goals and schedule availability.

Primary Concerns *(Select all that apply)

Anxiety Depression Trauma / PTSD Relationship Issues Stress Management Grief & Loss

Session Type *

Preferred Modality *

Best Times for Sessions

Additional Notes or Goals

Please review and confirm your understanding of our policies.

I acknowledge receipt of the Privacy Notice and understand how my information will be used. *

I agree to the Financial Responsibility Agreement and understand my insurance/copay obligations. *

I consent to electronic communication and digital signature for intake documents. *