Asking for help is hard enough, scheduling shouldn’t be!

Name of Intended Client *

First Name

Last Name

Date of Birth of Intended client *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Name of Parent

If services are for your child please put their name above and yours here. Skip if not applicable.

First Name

Last Name

What service(s) are you looking to participate in? *

Select all that apply

Individual Therapy (adult 18+)

Individual Therapy for child (under 17)

Couples Therapy

Biofeedback/Neurofeedback

Have you ever attempted suicide? *

Yes

No

Have you ever been hospitalized?

Yes

No

If seeking couples therapy or family therapy, is there currently any domestic violence or safety concerns within your relationship? *

Yes

No

N/A

What is the provider phone number on the back of the card? *

Country

(###)

###

####

Name of the policy holder (if different from identified client).

First Name

Last Name