Initial Interest Form

Initial Interest Form (Adults)

Please complete this form to provide more information about the services in which you are interested (for yourself or your adult child). Once it is submitted, an intake coordinator will contact you within 5 to 10 business days.
Client's Name*
Client's Date of Birth*

MonthDayYear
Client's Gender*

MaleFemaleOther
Primary Phone Number*
Secondary Phone Number
Please enter a valid phone number.
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What services are you interested in? Please check all that apply.*

Psychology (therapy)PsychiatryPsychological Evaluation
What concerns are leading you to seek these services?*

0/200
Have you undergone a previous evaluation for these concerns?*

NoYes
Please upload previous evaluations and/or other relevant documents.

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Is there anything else you would like us to know?

0/200
Insurance Company*
Insurance coverage is subject to provider plan and treatment.
Who completed this form?

Client/selfSpouse/PartnerCaregiver/parentOther
Spouse/Partner Name

First NameLast Name
Caregiver/Parent Name

First NameLast Name
Do you have legal guardianship over client?

YesNoOther
Please upload guardianship paperwork as applicable.

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Initial Interest Form (Adults)