Online Intake

First name

Last name

Email

Phone

Have you had therapy before?

Yes

No

What concerns are you looking to work on in therapy? (choose up to 3)

What insurance will you be using?

Are you using EAP benefits

Yes. I have an authorization number

Yes. I do not have an authorization number.

No.

If you have an EAP authorization number, please add it here

Is there anything you would like to share about your therapy needs? (not required, just useful to assign a therapist)

Thank you for completing this form. We will contact you soon about setting up an appointment.