Intake form

Are you currently experiencing thoughts of suicide?

Yes

If you’re feeling overwhelmed or struggling with thoughts of suicide, please know that you are not alone. There are people who care about you and want to help. You can reach out to the Suicide & Crisis Lifeline by calling 988 or visiting 988lifeline.org for immediate support. If you are in an emergency, please call 911 or go to the nearest emergency room. Your life is important, and reaching out for help is a strong and courageous step.

Please select a staff member you'd like to meet with.

Patient Details

Patient First Name(Required)

Patient Last Name(Required)

Are You a:(Required)

Minor

Adult

Home Phone

Work Phone

Mobile Phone

OK to Leave a Message?

Yes

Text

Call Only

Patient Speaks

English

Spanish

Patient Email(Required)

Date of Birth(Required)

Referred By

Name of Parent or Legal Guardian(Required)

First Last

Insurance Info

Do you have Insurance?

Yes

Name of Insured(Required)

Social Security #(Required)

ID Number(Required)

State issued(Required)

Upload a photo of your ID (optional)

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Name of Insurance(Required)

Insurance Co. Phone(Required)

Upload photo of insurance card front(Required)

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Upload photo of insurance card back(Required)

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Are You In Network?(Required)

Yes

Not Sure

Have You Been Seen Yet?

Yes

Benefits 1 of 2

Is Provider In Network?

yes

Type of Service Requested

Individual

Group

Couples

Family

Adolescent

CASOMB

Type of Appointment Preferred

Select Your Desired Location(Required)

Effective Date

Additional Notes

Claims Mailing Address

Street Address Address Line 2 City State ZIP Code

Patient Signature(Required)

Parent or Legal Guardian Signature(Required)

Date

Insurance Info

Do you have Insurance?

Yes

Name of Insured(Required)

Social Security #(Required)

ID Number(Required)

State issued(Required)

Upload a photo of your ID (optional)

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Name of Insurance(Required)

Insurance Co. Phone(Required)

Upload photo of insurance card front(Required)

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Upload photo of insurance card back(Required)

Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Are You In Network?(Required)

Yes

Not Sure

Have You Been Seen Yet?

Yes

Benefits 1 of 2

Is Provider In Network?

yes

Type of Service Requested

Individual

Group

Couples

Family

Adolescent

CASOMB

Type of Appointment Preferred

Select Your Desired Location(Required)

Effective Date

Additional Notes

Claims Mailing Address

Street Address Address Line 2 City State ZIP Code

Patient Signature(Required)

Parent or Legal Guardian Signature(Required)

Date