New Patient Initial Information
IF YOU (OR THE PERSON YOU ARE INQUIRING ABOUT) ARE IN DANGER OF HARMING ANYONE, DO NOT COMPLETE THIS FORM. CALL 911 OR HAVE SOMEONE TAKE YOU TO THE CLOSEST EMERGENCY ROOM IMMEDIATELY.
Referred by (only if relevant):
Who are you interested in obtaining treatment for?
Very briefly, what type of problem does that person want help with?
Using health insurance to cover treatment? Yes No
If yes, what type of health insurance?
Available for daytime appointments? Yes No
Interested in having first appointment sent to you? Yes No
If yes, to what email do you want the paperwork sent?

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