Data Collection Disclosure
We take your personal information very seriously. This form collects your personal information in order for us to evaluate your needs and schedule an appointment with the appropriate doctor or counselor. This form uses an encrypted secure connection and all data is stored in strict compliance with current HIPAA standards and can only be accessed by the authorized members of our team.
This form has the browser remember your information as you enter it until you submit the form, at which point all the information is cleared. This is useful if you accidentally close the browser or need to leave your computer and continue filling in the form at a later time. However, if you are using a public computer we strongly suggest that you complete and submit the form in a single sitting before leaving the computer.
Please review our privacy policy to see how we manage your submitted data.