Adult Intake Step 1 of 6 16% Name(Required) First Last Age(Required)Please enter a number from 0 to 100.Date of Birth(Required) MM slash DD slash YYYY Email(Required) Phone(Required) Would you like to use insurnace? Yes No Insurance Company Insurance ID Policy Holder's Name Are you currently in therapy?(Required) Yes No Have you been in therapy before?(Required) Yes No Most recent time in therapy? MM slash DD slash YYYY Have you had previous hospitalization for mental health or substance use concerns?(Required) Yes No If yes, please explain: Are you currently taking psychiatric medications for: Anxiety Depression Other Please list your current medicaitons: Are you currently facing legal action(s)?(Required) Yes No Please explain: Please give us a brief description of your concerns and goals for therapy.(Required)CAPTCHAOnce you have completed this form a member of our team will contact you to inform you of our placement procedures. Thank you for allowing us to assist you. We look forward to working with you.