Name *

First Name

Last Name

Birth Date

MM

DD

YYYY

Phone

(###)

###

####

Preferred Therapist

{If Applicable} Enter Name

First Name

Last Name

Insurance Member ID# *

If you're looking for OON services, write "OON"

First Name

Last Name

Insurance Group # *

First Name

Last Name

Check all that apply to what you’re going through. *

Suicidal Ideation

Homicidal Ideation

Self Injury

Substance Use

Specified Trauma

Open to Working with Clinical Intern?

We are a training facility and are proud of our clinical interns skills and abilities.

Yes

No

Indifferent