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Patient Intake Form

Help us understand your needs to find the most suitable clinician for you.

State of residence

Preferred language

Gender preference

Insurance provider

Appointment type

Urgency level

Clinical Needs & Specialities

Select all that apply to your situation.

Anxiety

Depression

PTSD

OCD

Bipolar Disorder

Schizophrenia

Personality Disorders

Trauma

LGBTQ+ Issues

Family Issues

Grief and Loss

Stress Management

Preferred time slots (Optional)

When would you prefer to have your appointments?

Morning (9am - 12pm)

Afternoon (12pm - 3pm)

Evening (3pm - 6pm)

Night (6pm - 9pm)