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Personality Disorders and Complex Trauma

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Personality Disorders and Complex Trauma

Specialized therapies for personality disorders and trauma.

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Intake Form

Step 1 of 3 - Patient Details

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Are you currently experiencing thoughts of suicide?

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No

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.

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Patient Details

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Referred By

Have You Been Court Ordered to Therapy??(Required)

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Name of Parent or Legal Guardian(Required)

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Is There a Custody Agreement?(Required)

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Are Restrictions Specified for Either Parent in the Agreement?(Required)

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Explain Restrictions(Required)

Are custody Issues present?(Required)

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Briefly Explain Issues(Required)

Insurance Info

Do you have Insurance?

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Are You In Network?(Required)

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Have You Been Seen Yet?

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Benefits 1 of 2

Is Provider In Network?

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Type of Service Requested

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Type of Appointment Preferred

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Parent or Legal Guardian Signature(Required)

Date

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Submit Your Resume

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Attach your Resume(Required)

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