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Major Insurance Plans Accepted

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Client Intake Form

Please fill out the following form to help us understand your mental health needs so that we can match you with one of our mental health professionals.

First Name

Email Address

Last Name

Date of Birth

Will you be paying for services out of pocket or using insurance? *

Out of Pocket

With Insurance

If you answered, 'With Insurance' please provide your insurance provider's name

What brings you to seek mental health services?

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

get the help you deserve

Click here to schedule an appointment

Stressed Woman

Mon.- Fri. 10:00 am- 5:00 pm

Saturday 10:00 am- 2:00 pm

Sunday Closed

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