Initial Appointment Request Form
Most answers are required so we can properly review your request and secure an appointment with one of our therapists. After filling out the form, we will follow up with you, via e-mail or phone, within 1-2 business days.
(FOR OFFICE USE ONLY)
Best number to reach you, and to receive texts from our office concerning scheduling or billing.
To be used for notifications from our offices regarding Patient Portal instructions, statements and forms to fill out.
Parent, spouse, partner, aunt, uncle, cousin, friend...

How can we help?

Most answers are required so we can better understand how best to assist you.
(i.e. who needs the treatment, background, current issues...)
In-person treatment subject to therapist availability
Primarily for when treatment will be in-person.
select all that apply

Payment/Insurance Information

Click or drag files to this area to upload. You can upload up to 2 files.
.PNG, .JPG, .DOC, or .PDF Format Only
Click or drag files to this area to upload. You can upload up to 2 files.
.PNG, .JPG, .DOC, or .PDF Format Only