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Home
Team
Services
Children’s therapy
Individual therapy
Couple therapy
Family therapy
Group therapy
Insurance & Fees
Get Started
Patient Intake Form
Email Address
*
Patient's First Legal Name
*
Patient's Last Legal Name
*
Patient's Date of Birth
*
Who is filling out this form?
*
Patient
Parent
Child
Partner
Friend
Other:
Best Contact Number
*
Patient's Home Address
*
Briefly: what made you/the patient want to begin therapy?
*
Are you seeking a particular type of therapy?
*
Talk Therapy
CBT (Cognitive Behavioral Therapy)
DBT (Dialectical Behavior Therapy)
Trauma Therapy
EMDR (Eye Movement Desensitization and Reprocessing)
Couples Therapy
Family Therapy
Children’s Therapy
Anger Management
Addiction Counseling
Grief Counseling
Unsure
Are you seeking a particular type of therapist (i.e., any personal or professional characteristics)?
*
Please upload a photo of the front of your insurance card for insurance verification.
*
Choose File
No file chosen
Delete uploaded file
Please upload a photo of the back of your insurance card for insurance verification.
*
Choose File
No file chosen
Delete uploaded file
If the picture of your insurance card is not uploading please share the following information:
Insurance company
Insurance ID
Group number
Your answer:
How did you hear about us?
*
Your answer
Google search
Alma
Psychology Today
Headway
Grow
Insurance referral
Good Therapy
Therapy Den
Other
Anything else you would like to share?
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