Appointment Request Form

Please correct the errors described below.

Please use this secure form to request an intake appointment. Our Client Care Coordinator, Christine, will contact you within 1-2 business days. We look forward to speaking with you!

Contact Information

Client Information

We need to know the client's age, in order to assign an appropriate therapist. Date of birth also helps us to check insurance benefits.
Having your policy number enables us to check your mental health benefits, so that we can provide you with benefit information when we contact you.

Please note that this is a request for an intake appointment and does not guarantee an appointment. We will review the information you have provided to determine whether we have a therapist available who would be a good fit. Our Client Care Coordinator, Christine, will be in touch within 1-2 business days.

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