New Client Appointment Request

If you are experiencing a mental health emergency, please call 911 for an immediate response.

Patient full legal name:

Patient date of birth:

Patient email address:

Patient phone number ###-###-####:

Submitter name:

Submitter email:

Submitter phone ###-###-####:

Patient Occupation:

Best days and times for appointments:

If necessary for the provider, are you willing to accept telehealth for service delivery?

Preferred gender of therapist:

Name of Insurance or EAP company

Insurance Member ID (if utilizing insurance):

What services are you seeking?

What issues/concerns are prompting you to seek our services at this time, and how long have you been experiencing them?

Have you had any therapy/counseling in the past? If so, did you find it helpful?

Have you ever had a psychiatric hospitalization?

Have you ever experienced suicidal thoughts, and acted in any way on those thoughts?

What medications are you taking for depression/anxiety/other mental health issues?

What is your preferred pharmacy (if seeking psychiatric medication management)?

(note that you will be returned to a blank form after pressing the button above)

If you are experiencing a mental health emergency, please call 911 for an immediate response.