New Client Contact Request Form

First name

Last name

Parent name

Parent phone number

Parent email address

Parent #2 name (if applicable)

Parent #2 phone number

Parent #2 email address

Date of birth

Current age

What type of insurance will you be using?

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

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

If the option were available, would you be willing to meet virtually for some or all of the assessment appointments?

Yes

No

What is the reason you are seeking care at this time? Please provide any additional information you would like us to have about your request.

What days/times are you available for appointments?

How did you hear about us?