New Client Intake Form

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Name (first, last)

Date of Birth (YYYY-MM-DD)

Phone Number

Reason for visit (please select one)

Reason For Visit (please provide as much detail as possible)

Current psychiatric medications and dosages (please type “N/A” if you are not taking any medications)

HIPAA Acknowledgement

By entering my name above, I hereby acknowledge receiving a copy of this notice. (Please click the HIPAA Acknowledgment button below to view/obtain a copy of our notice of privacy practices.)

HIPAA Acknowledgement

Thank you for completing our intake form.

Our intake coordinator will be in contact with you within two business days.