The purpose of this form (Intake Form) is to collect important information about your history and current symptoms, in your own words. We'll collect the basics, as well as information about your mental wellbeing, and your relational health. Please try to describe your situation as accurately as possible. Thank you!
Add another emergency contact
Do you experience any of the following? Use the dropdown menu and select the best option.
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Your information will be encrypted.
Your privacy is a top priority for us. We're confident in Hushmail's ability to protect your data. They're HIPAA-compliant and specialize in keeping medical information locked down.
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