Self-Pay Mental Health Intake Form

1

Name* This field is required.

First Name

Last Name

2

Email

example@example.com

3

Phone Number* This field is required.

Please include area code.

4

Location* This field is required.

Pennsylvania

Washington, DC (DMV)

Georgia

5

Gender* This field is required.

Male

Female

Non-Binary

Other

6

Date of Birth* This field is required.

Date

8

My Current Medications:Please list any medications you are currently taking or seeking to refill for yourself. If you are scheduling for someone else, please indicate their name and list of medications here.

9

I'm interested in:Please check all that apply for you or your family.

Individual Counseling $150

Couples Counseling $175

Child/Family Counseling $175

Psychiatric Evaluation (PA/DC only) $300

Medication Management (PA/DC only) $75

10

I learned about Preventive Measures from...* This field is required.

A Healthcare Provider

An Insurance/Agency Website

Google/Internet Search

A Radio Ad

Social Media

A Friend or Current Client

Community Event/Outreach

Community Liaison/PM Employee

Other

11

Are you interested in learning about Home Health Care Services or employment for you or a loved one? (Pennsylvania only)

Interested in Services

Interested in Employment

No interest at this time.

Type option 4

12

Please check the box to verify you are a human.* This field is required.