Welcome to Hope Behavioral Health.
In an effort to quickly and efficiently connect you with a therapist, this intake form collects all necessary and required information in order to begin counseling services. It takes about 5-10 minutes to complete.
- If the individual seeking services is under the age of 18, this form must be completed by a parent/legal guardian.
- You will need to upload copies of your driver's license and insurance cards (if you have insurance) before submitting this form.
Once this form has been submitted, we will contact you as quickly as possible. Upon receipt of your insurance information (if applicable), we will make every effort to verify your benefits and provide you with your projected out-of-pocket cost at your initial session. However, we strongly recommend you call your insurance company and verify your benefits for outpatient mental health services.
If you have any questions, please contact our intake department at (800) 642-4560, option 1.
Hope Behavioral Health
*All information is transmitted and stored securely and privately using JotForm, conforming to HIPAA standards.