Name*

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Service Requested*

Individual Counseling
Child/Adolescent Counseling
Couples Counseling
Psychiatry
Psychological Testing

Are you looking to use insurance?

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Treatment Setting Desired

In-Office
Telehealth (video)

Preference for Provider

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Preferred days and times for treatment

Please leave a short description of what has prompted you to seek treatment*

Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.

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Counseling, Psychiatry, and Psychological / Neuropsych Testing

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