Intake Form

Please fill out the following information carefully. All information will be kept confidential. Thank you for completing the intake form. Your information will carefully be reviewed and we will contact you as soon as possible.

Name

First Name

Last Name

Gender Identity

D.O.B

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Please provide details regarding your emergency contact's name, relationship to you, phone number and email address

Booking Preference

Preferred Session Frequency

Funding Details

Reason for Seeking Services

Please provide a brief explanation of the reason you are seeking support.

Additional Information

Please provide any additional information that you think is important for us to know.

How Did You Find Us?

Intake Form

Hours

Contact