New Clients

Let’s get started!
If you are interested in becoming a client, please complete the following form.

For assistance with an immediate crisis or mental health emergency, please call 911 or go to your nearest hospital.

Name

First Name

Last Name

Pronouns

Date of Birth

Phone

Primary Insurance Plan

Referred by

What are the main concerns you would like to address at this time?

Please describe any mental health or substance use treatment you have had in the past.

Do you have any scheduling restrictions or preferences?

Is there anything else you'd like me to know?

What is the best way to contact you?