Online Intake Form

Your Name (required)

Your Date of Birth (required)

Your Contact Phone Number (required)

Your Email (required)

Do you have a preferred location? Southpark or Ballantyne

Your Home Street Address (required)

Your Home City (required)

Your Home State (required)

Your Home Zip Code (required)

How did you hear about us? (if applicable)

Client's Name (if not individual listed above)

Client's Date of Birth (if not individual listed above)

Your Relationship to Client

Custody Status (if applicable)

School Attending (if applicable)

Insurance Provider

Subject

Do you have a preferred clinician, or were you referred to a specific clinician (please specify)?

Please briefly describe the situation you need to see someone about. If you are contacting us about testing services, please include if this is requested by a third party (school, court ordered, etc).

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