• Client Intake Form

  • Please complete our Intake Form to the best of your ability. Please note that, once submitted, the information is stored in a secure HIPAA compliant environment.

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  • Prenatal Period and Birth (Yes, this is helpful for adults too)

    Please tell us about your birth history, if known.


  • Infancy Health (Birth to 3 years - Check all that apply):







  • Health History (3 years through adulthood- Check all that apply)














  • Mental Health Considerations



  • Should be Empty: