New Client Form

Seeking support is a meaningful investment in your health and well-being. Whether you’re navigating a difficult season or looking to create lasting positive change, we’re here to walk alongside you. Please do not include sensitive medical or personal health information in this form.

Name *

Pronouns

Date of Birth

Email Address

Phone Number

Parent / Guardian Name (if client is under 18 years old)

What type of services are you seeking?Individual TherapyCouples TherapyChild/Adolescent TherapyFamily Therapy

Specific Requests

Preferred Therapist(s)

If the therapist(s) you listed above is not available, are you open to working with a different therapist?YesNoN/A

Payment OptionsInsuranceOut-of-pocket

Insurance Company

Insurance Member ID

Insurance Phone Number

Type of AppointmentTelehealth OnlyIn-Person OnlyEither Telehealth or In-Person

Mornings (8am - 11am)YesNo

Afternoons (12pm - 4pm)YesNo

Evenings (5pm - 8pm)YesNo

Is there anything else you want us to know about your availability for appointments?

If you were referred by another mental health or healthcare provider, please provide their name

Ready to Take the First Step?