IntakeInterested in working together? Fill out some info and we will be in touch shortly! We can't wait to hear from you! Name * First Name Last Name Preferred Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### What services are you interested in? * Individual + Couples + Family +Dog/Service Dog Emergency contact * First Name Last Name Emergency contact phone * (###) ### #### Marital Status * Single Partner Married Divorced Widowed Education * High School GED Some college Associates Bachelors Masters Doctorate Trade school/technical certificate Military Service None Reserve Active Discharged Separated Retired Spouse Dependent Job/Career * Describe your job or career, title, position...? Children/dependents Fostered, adopted, biological, step, minor or adult, dependent or independent Mental health Please list all diagnosis or struggles Mental health treatment? * Please explain all past and/or current mental health treatment Physical health * Please list areas of difficulties, diagnosis, and/or disabilities How did you hear about us? Web search Google Referred by a friend Referred by a counselor Referred by a medical doctor Referred by a veterinarian Message Thank you!
