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
*
-
Month
-
Day
Year
Client's Gender
*
Male
Female
Other
Primary Phone Number
*
Secondary Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What services are you interested in? Please check all that apply.
*
Individual therapy
Couples therapy
Family therapy
Psychological Evaluation for autism spectrum disorder
Psychological Evaluation for another disorder (examples: ADHD, learning disorder, anxiety, depression)
Please note: we are no longer accepting new psychiatry clients.
What concerns are leading you to seek these services?
*
0/200
Have you undergone a previous evaluation for these concerns?
*
No
Yes
Please upload previous evaluations and/or other relevant documents.
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of
Insurance Company
*
Insurance coverage is subject to provider plan and treatment.
Who completed this form?
Client/self
Spouse/Partner
Caregiver/parent
Other
Spouse/Partner Name
First Name
Last Name
Caregiver/Parent Name
First Name
Last Name
Do you have legal guardianship over client?
Yes
No
Other
Please upload guardianship paperwork as applicable.
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Is there anything else you would like us to know?
0/200
Submit
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