To become a new client, please fill out the form below. All new clients MUST fill out this form, in its entirety, to begin the intake process. If this form is not completely filled out, there may be a significant delay in starting services. Please begin by clicking next to the "First Name" field. 

If you are a private pay client, not using insurance, and DO NOT plan to use out-of-network benefits to receive reimbursement from your insurance company, please make sure you indicate that below so that you may be provided a "Good Faith Estimate" of the estimated cost of services. 




Do you consent to receiving emails?:
Who is completing this form?:
Referral Source:
Service(s) being requested (Scroll)?:
Payment Type (Scroll):
Are you providing receipts to insurance?:
Do you currently see another provider?:
Why are you seeing another provider?:
Specific provider you want to work with?:
Clinician Gender Preference?:
Preferred location of service?:
Briefly, why are you seeking services?:
Is there legal involvement?:
Is there current domestic violence?:
Recent substance abuse?:
Is this eating disorders related?:
Recent mental health hospitalization?:
Is the client 12-18 years old?:
Is the client under the age of 12?:
Relationship status of parents? (Scroll):
Who can make legal decisions for minor?:
Is DHS currently involved?:
DHS Case Contacts:
Insurance Carrier:
Insurance ID:
Subscriber's Name:
Client's DOB:
Client's legal gender (for insurance)?:
Address on file with insurance?:
Insurance Provider Phone Number: