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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.
19Questions
  • 1
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  • 2
    Please Select
    • Please Select
    • Yes
    • No
    • Follow up needed
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  • 3
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  • 7
    -
    Pick a Date
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  • 8
    Please provide the phone number of the parent or guardian who should receive updates and scheduling information.
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  • 9
    Please provide the email address of the parent or guardian who should receive updates and scheduling information.
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    • Huge
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    • Normal
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  • 15
    for example: after school, evenings, early morning, lunchtime, daytime, etc.
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  • 16
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    Substance use, suicidal ideation, self harm, etc.
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  • 18
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  • 19
    Please list referring provider if applicable
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