Intake Form

Before you can schedule your first appointment, we will need intake information about the new client and relevant parties. The intake form can be completed and submitted electronically below. Please fill out each answer as applicable. This will be sent via e-mail to our Intake Specialist, who will contact you according to your preferences. Please ensure that all information is filled out as accurately as possible.

If you do not wish to submit an online form, you can visit one of our locations in person to receive and fill out a physical copy of the intake form, or alternatively contact our intake worker by telephone.

You may not fill this form out for an individual besides yourself unless you have legal guardianship over this person or a release to legally do so.

Basic Information
Where are you seeking services? *
You may select multiple locations if applicable.
Name (of new client) *
Name (of new client)
Date of Birth *
Date of Birth
Gender *
Phone *
Phone
We will use this number to contact you. Please ensure it is accurate.
How may we contact you? *
If we can contact you by phone, may we leave a message?
Please note, for privacy purposes we can only do this if your voicemail includes your name.
Address *
Address
Does the client have a legal guardian? *
Parents and guardians
This section applies only to minors or those clients with legal guardians. Please skip this section if this does not apply to you.
If client is a minor or has a legal guardian, please describe the custody situation:
Legal Guardian's Name
Legal Guardian's Name
Legal Guardian's Phone Number
Legal Guardian's Phone Number
Second Legal Guardian's Name
Second Legal Guardian's Name
Second Legal Guardian's Phone Number
Second Legal Guardian's Phone Number
Insurance and Payment Information
How will you pay for services?
If you are paying with insurance, please fill out primary insurance information
Full name as it appears on insurance card
Policy Holder Date of Birth
Policy Holder Date of Birth
Please fill out secondary insurance information if applicable
Full name as it appears on insurance card
Secondary Insurance Policy Holder Date of Birth
Secondary Insurance Policy Holder Date of Birth
Guarantor name (if applicable)
Guarantor name (if applicable)
If using a Guarantor, please identify his or her name, address, and the relationship with the client. This person would receive monthly statements if applicable. If you are not using a guarantor, please skip this section.
Additional
We can attempt to arrange for a translator, if necessary.
Acknowledgement of Electronic Submission *