New Client Appointment Request

The form below is for first-time, new client appointment requests only.   While appointment requests are reviewed regularly, it is not intended for immediate response.

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.

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