Patient Registration FormPlease fill out the form below to help expedite your registration process. All information submitted through this form is securely transmitted to our private email account and is never stored on our website.Please enable JavaScript in your browser to complete this form.Personal InformationName *FirstLastPhone *Email *Emergency Contact Name *Emergency Contact Phone *AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAge *Sex *MaleFemaleEmployment Status *YesNoDisabilityRetiredMarital Status *MarriedSingleOtherSpouses Name *Time Preference for Service *MorningAfternoonEveningMay we contact you via email? *YesNoHow were you referred?OnlineFriendHealthcare ProviderInsuranceOtherType of Services Requested *Individual TherapyFamily TherapyMarital/Couples TherapyGroup TherapyPsychological TestingPsychological ConsultSubstance Abuse CounselingOtherBrief description of reason for seeking services *Are you currently experiencing suicidal thoughts or desire to harm yourself or others? *YesNoAre you seeking medication? *YesNoAny criminal or legal issues? *YesNoAre you seeking services for social security disability determination or other social security disability matters? *YesNoAre you having any drug or alcohol problems? *YesNoHave you ever been hospitalized for a mental health related condition? *YesNoAre you currently prescribed any psychotropic medications such as antidepressants? *YesNoAre you planning to self-pay cash check or charge at the time of service? *YesNoPsychotherapy self-pay prices range from $100.00 to $150.00Health Insurance InformationHealth Insurance Plan NamePolicy Holder / Member NameDependent NameHealth Insurance ID NumberGroup NumberDeductible / Co-payUpload a picture of your driver’s license and insurance card. Click or drag files to this area to upload.You can upload up to 2 files. Maximum file size 5MBSubmit