New Patient Intake Form
Choose the Right Therapy for Your Needs
Therapy and Appointment Preferences
Which service are you interested in?
*
Please Select
Therapy
Couples Therapy
Family Therapy
Medication Management
Grief Therapy
Psych Assessment
What are the reasons you're seeking therapy or medication management?
*
Please Select
Anxiety
Depression
Grief
Other (Please Specify)
Other (Please Specify)
Do you have a preference for a specific gender of therapist?
*
Please Select
No Preference
Male
Female
Is there a particular ethnicity you prefer for your therapist?
*
(Note: While we cannot guarantee your exact preference, we will make every effort to find the best match for you.)
Appointment Time and Day Preference:
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Weekday Mornings (8:00 AM-12:00 PM)
Weekday Afternoons (12:00 PM-5:00 PM)
Weekday Evenings (6:00 PM-9:00 PM)
Weekends (Saturday-Sunday, 9:00 AM-1:00 PM)
How soon would you like to be seen?
*
Please Select
Within the next 24 hours
Within next week
Within next month
How did you hear about Adaptive Behavioral Services?
*
Google Search
Facebook / Instagram
Friend or Family
Doctor / Referral
Community Event
Online Ad
Other
Contact Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is this a cell phone?
*
Yes
No
Please upload photo of your Driver's License (Max 2 files):
*
Browse Files
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Insurance Information
Insurance Company Name:
*
Insurance ID#:
*
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