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?

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)?

Is there anything else we should know about your request?

(Note that you will be returned to a blank form after pressing the button below)

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