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.
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