Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Best number to reach you

(###)

###

####

Provider's Name *

First Name

Last Name

Type of Mental Health Provider *

Therapist (Counselor, Social Worker, Psychologist, etc.)

Psychiatrist/Psychiatric Nurse Practitioner (can prescribe medication)

Primary Cary Doctor

Social Worker (other than therapist)

Other

Phone 1

(###)

###

####

Provider's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do we have your permission to contact your provider if needed? *

We may have questions about their paperwork or want to work with them to better meet your needs.

Yes, and I am willing to fill out a Release of Information for this purpose

No

Do you have Medicaid health insurance? *

If yes, skip the remainder of the Financial Information Section.

Yes

No