Intake Form

Intake Questions

Please complete this brief form to request services. This helps us ensure we are a good clinical fit and match you with the appropriate provider.

If you are in crisis or need immediate help, please call or text 988 or go to your nearest emergency room.

Full Name

First NameLast Name

Date of Birth

Medical Insurance

Services are not covered by Medicare.

If insurance is not listed, which insurance would you like to use?

E-Mail Address

example@example.com

Preferred Phone

Please enter a valid phone number.Format: (000) 000-0000.

Referred By (Please specify: Google, Insurance, Primary Care, Therapist, etc.)

Current Employer or School Attended

What type of care are you seeking?

What are you hoping to get help with?

If other, please describe what we can help with

In the past 2 weeks, have you had thoughts of harming yourself or others?

Have you attempted suicide in the past 60 days?

Are you experiencing hallucinations or severe mental health instability?

What days/times typically work for you?

Are you seeking in-person, virtual, or hybrid therapy?

How did you hear about us?

Our team will review your request and contact you shortly (typically same business day) to assist with scheduling and ensure appropriate clinical fit.

Crisis Message

If you are in immediate danger or need urgent help, please call or text 988, or go to your nearest emergency room.

Based on your responses, our outpatient services may not be the best fit at this time.

If you are in immediate need of support, please:
• Call or text 988 (Suicide & Crisis Lifeline)
• Go to your nearest emergency room
• Call 911

If you believe this was selected in error, you may contact our office directly.

How can we help you?

Psychiatric/Medical History

Current Medications (Medical and Psychiatric)

History of Hospitalizations with Approximate Date(s)

Have you ever had thoughts of self-harm or suicide, or a past history of either?

Have you ever had a history of or currently struggle with substance use, including drug or alcohol dependence or methadone maintenance?

Legal History

Is there anything you’d like to share with your provider and what are you hoping to achieve or experience through this process?

Please verify that you are human

Date/Time of Form Submission

Date

Hour MinutesAM/PM Option

utm source

utm medium

utm campaign

Status

GCLID