Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Daytime Phone *

(###)

###

####

Please indicate for whom you are seeking services

Myself

Child

Sibling

Friend

Professional Client

Other

Are you currently seeing any other mental health provider?

Yes

No

Have you ever been hospitalized for psychiatric reasons? *

Yes

No

Do you plan to use a health plan to pay for these services? *

Yes

No

Do you have Medicare as either a primary or secondary policy?

Yes

No

Date or birth of subscriber on insurance policy? *

This information is necessary for checking insurance benefits

MM

DD

YYYY

What type of service are you primarily seeking? *

Individual Counseling

Psychiatric Appointment

Group Psychotherapy

Neuropsychological Assessment

Coaching Services

Other

How would you like these services delivered? *

In-Person

Telehealth

Hybrid