Thank you!In order to expedite the intake process, please fill out the form below. A member of our team will be in touch soon. Does the patient have insurance? * Yes No Patient's name (as it appears in ID) * First Name Last Name Patient's date of birth (DOB) * MM DD YYYY Insurance Provider * (Aetna, Cigna, UnitedHealthcare, Medicaid, etc...) Insurance ID # * What is your relation to the patient (select "Self" if the appointment is for you) * Self Spouse/Partner Parent Grandparent Child Other If you are NOT the patient, please type your name and contact information Has the patient been treated for mental health or substance abuse in the past? * Yes No I don't know If yes, when / how long / where? Address Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you! A member of our team will contact you soon
