Please complete this form to request mental health services.

1. I am requesting services for:

My Child

Myself

My Family

My Partner & Myself

2. Form Completed By:

Full Name *

3. Patient Information

First Name *

Last Name *

Preferred Name

Date of Birth *

Sex *

Male

Female

Other

Gender Identity (if different from sex assigned at birth)

Street Address *

Apt/Suite

City *

State *

Zip Code *

Home Phone

Mobile Phone *

Email *

Do you consent to receiving emails? *

Yes

Desired Modality

Please select your desired modality *

4. Insurance Information

Insurance Type (select all that apply) *

Private Pay

Commercial Insurance

Medicaid

EAP

5. Primary Insurance

Primary Insurance Provider

ID Number

Subscriber is:

Subscriber ID *

Do you have secondary insurance?

Yes

8. Prior Counseling

Have you had counseling before? *

Yes

9. Signature

By typing my initials below and checking the confirmation box, I acknowledge that I understand this is a request for services. Submitting this form does not guarantee services, and I understand that someone will contact me to discuss next steps. I confirm that the information I have provided is accurate and complete to the best of my knowledge.

Digital Signature (Type your initials) * *

I confirm that the information submitted is accurate and complete to the best of my knowledge. *

Your information is protected by HIPAA privacy standards.