Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Please indicate for whom you are seeking services *

Myself

Child

Sibling

Friend

Professional Client

Other

Are you currently seeing any other mental health provider? *

Yes

No

Have you ever been hospitalized for psychiatric reasons? *

Yes

No

Do you plan to use a health plan to pay for these services? *

Yes

No

Do you have Medicare as either a primary or secondary policy? *

Yes

No

Date or birth of subscriber on insurance policy? *

This information is necessary for checking insurance benefits

MM

DD

YYYY

What type of service are you primarily seeking? *

Individual Counseling

Psychiatric Appointment

Group Psychotherapy

Coaching Services