• Intake Form

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • What type of care are you seeking?*
  • Are you taking three or more daily prescription medications of any kind?*
  • Would you like to start with therapy, start with medication, or begin both at the same time?*
  • What are you hoping to get 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?*
  • Have you been hospitalized or in an intensive outpatient program for mental health in the last three months?*
  • Are you currently in treatment with Suboxone, methadone, or another medication for opioid or alcohol dependence?*
  • Have you ever been diagnosed with a psychotic disorder, such as schizophrenia or schizoaffective disorder?*
  • Have you ever been diagnosed with bipolar disorder?*
  • Are you seeking in-person, virtual, or hybrid therapy?*

  • Once you submit, our intake team will call you from (203) 651-5117 within the hour, or first thing on our next open day (Monday to Thursday 8am to 6:30pm, Friday 8am to 3pm), to match you with a clinician and go over cost.

  • Based on your answers, we want to make sure you have support right away. If you are thinking about harming yourself or someone else, call or text 988 any time. If you're in immediate danger, call 911 or go to the nearest emergency room. You can still submit this form, but it isn't monitored in real time and submitting it doesn't start care.
  • Based on your answers, the type of care you need isn't something our practice offers. We provide standard outpatient care, and your situation calls for a program with a higher level of support than that. This is about what we're able to provide, not about you. You can still submit this form; we'll email you resources for finding that level of care. If you're in crisis, call or text 988 any time, or 911 if you're in danger.
  • Date/Time of Form Submission
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: