Let’s Get Started… Patient Information Name * First Name Last Name Email * Phone (###) ### #### Date of Birth MM DD YYYY Insurance * Is patient a minor? * Yes No If yes, please provide parent or guardian info: What would you like help with? * Any important mental health history you think I should know: Preferred Date MM DD YYYY Thank you! If you are having any thoughts of harming yourself or someone else, please call 988 or emergency services in your area.
