I am: *

over 18 years of age and seeking care for myself

a parent or guardian acting on behalf of a minor

Name of person completing this form *

First Name

Last Name

Phone

(###)

###

####

Which type of appointments are you seeking?

Please note that intake appointment(s) are strongly preferred to be in-person

In person

Virtual/Telehealth

Hybrid of both

Please select all that apply to you or your child:

Never taken psychiatric medication before

Taken meds in the past, but none currently

Currently taking meds prescribed by another provider

Never been in therapy before

Tried therapy in the past, but not currently

Currently seeing a therapist (or actively looking for one)

Checking the box below indicates that you have reviewed the practice policies available under the "Forms" page prior to submitting this request: *

I have reviewed the policies & understand that I will sign the agreement before scheduling an initial appointment.