Secure New Client Contact Form

Please Complete Form and Upload Front and Back of Insurance Cards

Thank you!

Telephone 302-359-3734

First name

Last name

Email address

Phone number

Date of Birth

Home Address

Are You Been Seen For:

FMLA

Car Accident

Worker's Compensation

N/A

Being Seen For:

Mental Health Counseling

Medication Management

Couples Counseling

Other

Brief Reason for Being Seen

Are You Currently Being Seen by Another Mental Health Provider? If Yes, Who?

Preferred Appointment Day/Time

Do You Have Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

Front and Back of Primary Insurance Card

Add file

Please upload a file

Front and Back of Secondary Insurance Card

Add file

Please upload a file

Policy Holder Information

Please input: Relationship (Parent, Child, Spouse, etc.), Name, Date of Birth, and Address for the Policy Holder. Please type "Self" if you are the Policy Holder

Your information will be encrypted.