New Client Contact Request Form

First name

Last name

Email address

Phone number

Do we have permission to leave a voicemail? Please note that unless expressly asked not to, we will likely initially reach out to you via email.

Yes

No

Name of primary care provider

Clinic name for primary care provider

Date of birth of the intended client

What type of insurance will you be using?

If you are requesting services for someone else, please explain and provide the name of the intended client.

Please select the service(s) you are requesting.

Individual therapy for myself

Couples therapy

Individual therapy for a child

Family therapy

Psychological testing for myself

Medication management

Psychological testing for a child

If the clinician you requested is not available, would you be open to referral to one of our colleagues?

Yes

No

What is the reason you are seeking care at this time?

What days/times are you available for appointments?

How did you hear about us?