New Client Appointment Request Form

Please Note - As of 8/29/22, our clinicians are all fully booked. I will update this form as soon as we have more openings. This brief form helps us determine if we have a good fit on our team.

Please correct the errors described below.
We have clinicians on our team who are immunocompromised and/or have family members in their home who are unable to be vaccinated. Your vaccination status will help us match you to an appropriate clinician and will NOT impact your ability to receive services, potentially in our office or virtually.

Your information will be encrypted.