Initial Intake Form

You’ve already taken the first step; now let’s take the next step together. Complete and submit the form below to begin the intake process.

Your Name (adult client or caregiver)(Required)

First Last

Email(Required)

Phone(Required)

Client's Name (if different from above)

First Last

Client's Date of Birth(Required)

I am interested in:

Individual Counseling

Couples Counseling

Family Counseling

Preferred Method Of Payment(Required)

Self-Pay

Insurance

Your Insurance Plan (if preferred method of payment)

Please describe why you are seeking counseling services.(Required)

Preferred Session Type(Required)

In Person

Telehealth (via Zoom)