First Name *

Last Name *

When would you have availability to come in for appointments? (Please note that evening and weekends are the most in demand and have less availability.)

Would you prefer to meet with a therapist in person or online?

Prefer in-person only

Prefer online/telehealth

Open to either

Is this appointment for your child?

Is this appointment for yourself?

Date of birth *

Parent/Guardian's Name *

Child's First Name *

Child's Last Name *

Partner's Last Name *

Partner's First Name *

Partner's Email *

Custody Status of Minor *

Would you like us to check your insurance benefits?

Insurance

If have health insurance, which carrier do you have?

Client Name (exactly as listed on the insurance card)

Insured subscriber ID# (Please Include the 3 letter prefix if you have one or 9 digit primary number + 2 digit suffix.)

Insured Group Number

Insurance Phone Number

Who referred you?

How did you hear about us? *

HIPPA Privacy: *

I agree to the privacy policy

Disclosures