Patient Name

Parent or Guardian

Address

City State Zip

Phone Number Date of Birth

email address

How did you here about our office

Insurance Provider

Are you currently in counseling

Below please describe what difficulties or problems prompted you to contact our office.

Sleep -  Good  Bad  Ok Not at all Other

 How have your moods been- (check all that apply)Sad Happy Angry Crying Nervous Devastated Other

Where you referred to a specific provider

Please download the following appropriate forms:

Please read and complete all of the included forms and bring them with your insurance card to your first appointment.

Download Adult Forms  

Download Child Forms