How can I help?

Would you like to get services started? There is currently no waiting list.

Client Name

First Name

Last Name

Client Phone

(###)

###

####

Client Email Address

I’m interested in the following service(s) ...

Individual Therapy

Family Therapy

Psychological Evaluation

Co-Occurring Evaluation (Mental Health + Substance Use)

Substance Use Evaluation

Client Date of Birth

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have insurance?

Yes

Insurance Company + Policy Number

Referral Source

Referral Contact Information

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