(only required if a minor)

If your therapist is not listed above, please enter here:

Street address, P.O. box, company name, c/o

Apartment, suite, unit, building, floor, etc.


State / Province / Region

Postal / Zip Code

Please provide two ways of contacting you
in the fields below

What phone number would you prefer we call for necessary communications and in the event of scheduling questions?

In the event that we cannot speak with you directly, may we leave a voicemail on your preferred phone?

If you would like to add a secondary phone number for necessary communications or the event of scheduling questions, please enter the number here:

May we leave a voicemail?


  Employment & Insurance Information:


(this information is often on the back of your insurance card)

(if other than you)

(if other than you)

(if listed on insurance card)

At this time, you have the option to securely upload your Health Insurance ID with your smartphone or computer.

You may also securely submit just your Health Insurance ID later from the NEW CLIENT portal accessible via our homepage.

Upload Additional


  Personal & Medical Information:


If so, what are their ages?

(if applicable)


  Mental Health History:


Have you ever been in therapy before?

If so, for how long?

(if applicable)

Do you use alcohol?

If so, how much and how often?

Do you use tobacco products?

If so, what kind and how often?

Do you use any other drugs?

If so, what types, how often and when?

What are the current stresses influencing your mental health?

What are your related concerns?

Is there a history of depression or anxiety in your family?

If so, what family member(s) and what condition(s)?

If so, did they receive treatment in the past?

Are they still receiving treatment today?

May we email you regarding future events or workshops at the Center?

Please note: If uploading images, the form may take up to a minute after pressing submit. Your patience is much appreciated.

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