Intake Form

Information Section
Legal Name:*

First NameLast Name
Preferred Name:
If different from legal name.
What is your date of birth?*

MonthDayYear
Age:*
What is your legal sex as listed on official documents?*
e.g., government-issued ID and insurance records. This information is required to file insurance claims.
Social Security Number*
What is your current address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your email?*
example@example.com
What is your phone number?*
Please enter a valid phone number.
Can we send you text messages about your appointment?*

YesNo
Can we call and leave a voicemail?*

YesNo
If you were referred to us, please tell us the doctor or organization?
Are you seeking couples counseling?*

YesNo
Are you utilizing an Employee Assistance Program (EAP) for your services?*

YesNo
Tell us why you are seeking therapy?*
New medical diagnosis, personal goals, life events, etc. Our clinicians do not provide medication management, court testimonies, or documentation for work, school, or any legal matters. This includes letters for medical marijuana, employment, immigration, or fitness to serve issues.
Please upload a photo of your government-issued ID or driver's license as it is required for verification purposes.

Please ensure that the photos are clear and all information is visible.
FRONT OF ID*
BACK OF ID*

New patient intake