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Our Providers
Client Portal

New Client Intake Form

Name (first, last)(required)

Email(required)

Phone Number(required)

Reason for visit (please select one)(required)

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

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

HIPAA Acknowledgement (required)

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.)

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HIPAA Acknowledgement

Thank you for completing our intake form.

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