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Name of Patient*

Patient's DOB*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number*

Email Address*

Preferred Method of Communication*

Email
Phone
Both

Insurance Company Name*

Insurance Identification Number*

Insurance Group Number*

Referred by*

Type of Patient*

New Patient
Existing Patient

Type of Appointment*

Individual Therapy
Couples Therapy
Medication Management
Family Therapy
Substance Abuse Therapy

Are you currently seeing a therapist?*

No
Yes

Are you currently being prescribed any psychiatric medications?*

No
Yes

Treatment Goals*

If under 18: is there a current or pending custody agreement*

No
Yes

If joint custody, name and contact information of the other parent*

If over 18: are you applying or plan to apply for disability or extended leave of absence from work*

No
Yes

Desired Day/Date*

Desired Time*

When you submit this online request please do not also leave a voice message at our office. We will respond to your request via phone call or email within 24 business hours. We look forward to working with you!

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