If you are a new patient, making your first appointment is an easy three-step process.

Step 1: Please fill out the form below and click "Submit"; you will then be taken to a Thank You page for Step 2.

Step 2: On the Thank You page, please click the button to fill out the online Disclosure Form.

Step 3: Book an appointment online.


New Patient Intake Form

Your Name *
Your Name
Date of Birth
Date of Birth
Gender
Address
Address
Phone - Cell Number
Phone - Cell Number
Is it acceptable to call and leave a message on your phone number?
Is it acceptable to contact you via your email?
Please note: Email correspondence is not considered to be a confidential medium of communication.
Marital Status:
If yes, please explain/describe
If yes, please give the name, date, and location of the therapy and briefly explain the nature of the problem that required attention.
Please check any of the following struggles that pertain to you:
Emergency Notification
In case of emergency, please notify:
Name
Name
Phone
Phone
Goals