New Client Intake

Please complete the form below to get started. All information is kept strictly confidential and HIPAA compliant.

Personal Info

Contact & Emergency

Insurance & Billing

Clinical & Consent

Personal Information

Help us get to know you better. All fields marked with * are required.

First Name *

Please enter your first name.

Last Name *

Please enter your last name.

Date of Birth *

Please select your date of birth.

Gender

Pronouns

Contact & Emergency Details

How we can reach you and who to contact in case of emergency.

Email Address *

Please enter a valid email address.

Phone Number *

Please enter a valid phone number.

Mailing Address

Emergency Contact Name *

Required field.

Emergency Contact Phone *

Required field.

Insurance & Billing

Provide your coverage details. If you're self-pay, leave insurance fields blank.

Insurance Provider

Policy / Member Number

Group Number

Preferred Payment Method

Billing Notes (Optional)

Clinical Intake & Consent

Briefly share what brings you to therapy and acknowledge our policies.

Reason for Seeking Therapy *

Please share a brief reason for your visit.

Current Medications & Dosages (Optional)

Previous Therapy or Hospitalization? (Optional)

I consent to participate in therapy and understand the nature of treatment, risks, benefits, and alternatives. *

You must consent to proceed.

I have read and understand the Notice of Privacy Practices (HIPAA) and consent to the disclosure of my protected health information as described. *

You must acknowledge HIPAA policies.

I agree to the fee structure and understand my financial responsibility for services not covered by insurance. *

You must acknowledge fee policies.

Electronic Signature *

Please type your full name to sign.

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Forms Submitted Successfully

Thank you for taking this important step. Our intake coordinator will review your information and reach out within 24 hours to schedule your initial consultation.

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