We're so glad you're here! Taking this first step toward support is a big deal, and we're honored to be part of your journey. To help us connect with you in the best way possible, please let us know who is completing this form. *

Individuals 18 years or older must complete their own intake paperwork and provide their own contact information (phone/email); if you are a family member or friend filling out this contact form on their behalf, please indicate so.

Self (18+ and providing own information)

Family Member or Friend

Name *

First Name

Last Name

Phone

(###)

###

####

Are you a new client?

Yes

No

Would you like your visits submitted to insurance? *

Yes

No

Choose 1: *

By checking this box I consent to have my insurance benefits pulled for the purpose of an out of pocket estimate for services.

or I don’t need an estimate, I know my insurance benefits and I am ready to schedule.

Time of day that works best for you:

Morning

Midday

Evening