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Who would be receiving care?

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Reason for care
If yes, please note brief description and dates/outcome of treatment
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If yes - Substance type, frequency, amount?
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If yes, type of harm, last date(s) of harm (ex: self-injury, physical fights with others, etc).
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If yes, please briefly explain:
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Administrative
Enter how you were referred to our services (ie., Psychology Today, website, friend/family member, other therapist).
Do not upload sensitive financial information such as credit card information.
Billing & Payment
How do you plan to pay for services rendered to you?
Please note insurance type(s), insurance ID# and subscriber information/date of birth
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Upload a photo of your insurance card
Client Preferences
Appointments are held on Tuesdays-Fridays at this time:
For example: what you'd like to focus on, insurance or payment questions, etc.
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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.