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Welcome

Please provide accurate and detailed information so we can best support your care and connect you with the right specialists. Your health and well-being are our top priorities.This confidential form is sent to our clinical director for review. If you are having a mental health emergency please dial 911 or proceed to your nearest emergency room. If you need to reschedule or cancel an existing appointment please place a request through your Patient Portal.
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    Pick a Date
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    Please provide the phone number of the parent or guardian who should receive updates and scheduling information.
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    Please provide the email address of the parent or guardian who should receive updates and scheduling information.
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    Days or times of day that you need to make appointments work (for example: after school, evenings, virtual, daytime, etc)
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    Substance use, suicidal ideation, self harm, etc.
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