New Clients

New Client Intake Form

Thank you for reaching out. Please complete this form before your first session so we can best prepare to support you and your family.

Client Information

First Name*

Last Name*

Email Address*

Phone Number*

Date of Birth

Is the client a minor (under 18)?

No — I am the clientYes — I am a parent/guardian

Street Address

City

State

ZIP Code

Full Name

Relationship

Phone Number

Main concerns or reason for seeking therapy*

How did you hear about us?

Service you're interested in

Preferred session format

Online (telehealth)In-personNo preference

Your information is kept strictly confidential and protected under HIPAA.