New Patient Inquiry

New Patient Inquiry

After you submit this form, a member of our intake team will call you at the scheduled time you pick from the calendar below to give you your appointment.
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Services Requested
Address

CityState

Zip Code
Please select a convenient time for a brief phone call with our intake team to review your Intake Packet, answer your questions, and schedule your first appointment.
Thank you for taking your “First Steps” with us. After you submit this form, you will get a confirmation email with a link to the Intake Packet. We encourage you to finish the packet before your meeting, but if you have a “Misstep,” we can “Walk” through it together.
Terms of Use
By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Lifespan Behavioral Health Services harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.
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