New Client Registration
If you are a new client, complete this form so we can start matching you with a therapist and scheduling your first appointment. Please choose a time for a call back to avoid any phone tag while we are onboarding you as a client. This form is HIPAA compliant and your information is secure.
Contact Information
Parent/Guardian Name (if potential client is a child)
First Name
Last Name
Potential Client Name
*
First Name
Last Name
Date of Birth
*
Please select a day
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Please select a year
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Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
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How Can We Help?
What issues are you dealing with? Check all that apply.
*
Anger
Anxiety/Worry
Career Planning
Chronic Illness
Depressed Mood
Disordered Eating
Divorce
Family Conflict
Friendship Issues
Grief/Loss
Infertility
LGBTQ+ Topics
Life Changes
Marriage/Relationship Issues
Parenting Support
Perinatal/Postpartum Support
Premarital Counseling
Problems at School
Problems at Work
Self-Esteem
Self-Injury
Sleep Issues
Spirituality
Stress Management
Social Skills
Trauma
Other
Please provide more specific details about why you are seeking counseling:
*
For minor clients only: Describe who has custody of the child and if there are any issues related to divorce/separation of the child's parents.
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Insurance Information
Insurance Card Front
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Insurance Card Back
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Schedule an introductory call with our intake staff. During the time slot you choose, we will call you to confirm your information, match you with a therapist, and schedule an appointment. (If we have the opportunity to call you earlier we may try!)
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