New Appointments

Please note that not all therapists are providing in-person visits at this time. See below for information.

Legal Name (as registered with your insurance company)*

First NameLast Name

Preferred Name

First NameLast Name

DOB*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

Phone Number*

Area CodePhone Number

E-mail*

Known Mental Health Diagnosis

Are you seeking medication evaluation from us? We do not conduct medication evaluations. Please contact your insurance company for a referral.*

No

Primary Reason for Appointment*

Name of Guardian Completing Form if Applicable

Not all therapists are taking new patients. Please select your preference. We will contact you to let you know whether or not that therapist is available to see you.

Click here to view therapists' profiles.

Would you prefer In-Person or Telehealth?*

Who is your first preference?*

Who is your second preference?*

Insurance Member ID/Subscriber Number*

Please upload a photo of the front of your insurance card.

Upload a File

Were you in contact with the therapist you selected and he/she asked you to make an appointment?*

YesNo

Please give us some dates and times that you are available.*

We require a valid credit to be on-file for any copays, deductibles and last minute cancellations. You may also contact our office to give us this information. We cannot confirm your appointment until we have this information.

If you are a referring provider, please give us your name and contact information. If you are not, please enter "N/A".*

Please let us know if there is anything else you'd like to share with us (disability accommodation, language needs, etc.).

You may securely upload any pertinent patient information.

Upload a File

How do you prefer us to contact you?*