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Who would be receiving care?

Your info

Select the state you live in
Reason for care
Medication services are not offered | لا نقدم خدمات العلاج الدوائي
Client Preferences
For example: What you’d like to focus on, payment questions, any therapeutic preferences | مثل: ما الذي ترغبين بالتركيز عليه، استفسارات حول الدفع، أو أي تفضيلات علاجية
Limited to 600 characters
Your clinician may use AI tools (such as using AI to generate an intake summary) to help support your care. Your information is protected under HIPAA and anything generated by AI is always reviewed by your clinician. AI does not make decisions about your care. You can withdraw this consent at any time by contacting your provider without it impacting the care you receive.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.