Important Information for Completing This Form

This form is intended for individuals aged 12 and older who are personally seeking mental health services independently, without the assistance of a parent/guardian. Please note the following important details before proceeding:

1. For Self-Referral Only: This form is specifically for individuals requesting services for themselves. If a friend or family member is completing this form on your behalf, please remember that we cannot discuss any details with them unless you provide a signed release of information form. Without this authorization, we will reach out to you directly.

2. Mental Health Psychotherapy Only: Please note that we do not offer medication services at this time; our services are limited to mental health psychotherapy services.

3. Answering Questions: If you encounter any questions you’re unable to answer, please type “N/A” in the response field to continue with the form.

4. Accepted Insurance Plans: For a list of insurances we accept, [click here]

5. Additional Forms:

   • For individuals such as children/others with a parent/legal guardians, [click here for the guardian form].

   • For couples seeking services, [click here for the couples form].

Thank you for your understanding and cooperation. We look forward to connecting with you.