Contact Forms Contact FormPlease enable JavaScript in your browser to complete this form. Message Name Number Name *FirstLastPhone Number *Email *MessageSubmit 15-minutes free Phone Consultation Appointment Request FormPlease enable JavaScript in your browser to complete this form. Name Email Number Name *FirstLastPhone Number *Email *MessageSubmit Consultation Contact Form for Invited Workshops, Talks & Presentations Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone Number * Name Comment Workshop Email *Organization *Time Frame when Workshop or Invited Talk Participation is requested *Comment or MessageSubmit Clinical Supervision FormPlease enable JavaScript in your browser to complete this form.Name *FirstLast Status Name License Email *InstitutionDegree pursuingLicense StatusComment or MessageSubmit New Client Intake FormPlease enable JavaScript in your browser to complete this form.Your Name *FirstLastDate of Birth *Age *Home Street Address *City *State *Zip Code *Email Address *Phone Number *Parent/Guardian Phone Number *Gender *Marital Status *Ethnicity *Religion *Insurance *Insurance ID *Front and Back copy of the Insurance card *Private PayYesNoIf you are a student, list name of School/ College/university *Are you currently working? If not, then please list the reason *Field of Work *Employer NameSelf-employed Name of BusinessEmergency Contact Name *Relationship *Contact Number *Reason/s for requesting Psychological and Behavioral Health Counseling and Therapy Services: Recent Changes in Life Do legal them Medical and Psychiatric HistoryConditions / Previous Diagnoses MedicationsHospitalizationsDo you currently take any medications for medical and psychiatric reasons? Please list them and their dosages, *If you do. Please Mention your Medications, Name of the PrescriberDo you have any chronic or recently diagnosed medical conditions? *Please Mention Your Primary Care Physician, Medical Practice Clinic Name, Phone Contact Number,Do you use any substances?YesNoAre you or have you been experiencing suicidal feelings? YesOrHave you received counseling and psychological treatment before?WhenWhereName of the ClinicianHas it been helpful?Do you feel safe in your living environment and relationships?YesNoDo you have any legal history? *YesNoAny other information you would like to sharePlease list your Treatment Goals *Signature and Date *Submit Find our more forms below Consent FormDownload NE Behavioral Health Cancellation or No-show Fees AgreementDownload Release of Information (ROI) FormDownload AssessmentDownload
