Intake Form

To request services please fill out this form and our office will contact you within a few days. It may take a few days to verify your insurance and we will email you the rest of the intake paperwork.

We are not scheduling new testing clients at this time, but will add new clients to our waitlist

Name

First Name

Last Name

Parent/Guardian Name and Contact Info

If individual is a minor or has a guardian

Date of Birth

YYYY

Phone Number

(###)

###

####

Services You're Requesting

Specify if you would like testing and/or therapy.

Reason For Services

Please include the reason you are requesting services (ie anxiety, adhd, etc), so we can match you up with the right clinician and assessments.

Insurance Company and Policy/Member Number or ID

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Care Provider and Clinic

Sex Assigned at Birth

This is required for billing insurance. You can also include your gender/pronouns.

Who Referred You For Services

Many insurance companies require a medical referral for testing

Preferred Contact Method