Client Intake

I authorize the release of any information necessary to my insurance plan or EAP to process claims, determine medical necessity or to request additional sessions. {I agree my electronic signature is the legal equivalent of my manual signature.} *

New Client Information

Please submit prior to your appointment.

To serve you with excellence, I need to know you better.

Please fill in this form thoroughly and tell me what will aid me in support you best.

**NOTE: Your information is totally secure. This site is Firewall protected. {Firewall = a system designed to prevent unauthorized access to or from a private network.}

Absolutely NO data is saved on this site at any time.