Lets Get started Please fill out this intake if you would like to schedule an appointment Name * First Name Last Name Email * List of current medication * if none please type NA Date of Birth * mm/dd/yyyy Last Psychiatric Hospitalization * if none please type NA Name of Health Insurance * if you are not using health insurance type NA Under whose name is your health insurance policy listed? * Are you currently seeing a therapist? * Yes No Searching Unwilling What would you like to share about your needs at this time? * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Were you referred? Please share their name Thank you!