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FAQ
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Home
New Patients
Providers
FAQ
Contact
New patients seeking therapy
For patients seeking an appointment with a psychologist or therapist, please complete the form below and we will contact you as soon as possible with available appointments.
Patient's Name
*
First Name
Last Name
Patient's Phone
*
(###)
###
####
Patient's Date of Birth
*
MM
DD
YYYY
Patient's Gender
Female
Male
Other
Insurance Info
*
Referral Source
*
Previous Diagnosis
*
Type "N/A" if no diagnosis has been given.
Interest in a Particular Treatment
*
Do you prefer certain types of therapy?
For Minors Only:
Legal Guardian Name and Relation
*
DHS Involvement
No
Yes
Any Current Legal Issues and/or Custody Disputes?
*
Patient's Street Address
City
State
Zip
Email
Notes
Thank you! We will contact you soon.
