Request an Initial AppointmentWe are here for your mental health journey! Please complete this form if you are looking to request an initial appointment or receive more information about our services. Our caring intake staff respond to inquiries during business hours. Please enable JavaScript in your browser to complete this form.General InformationPatient's Name *FirstLastPatient's Date of Birth *Email *Phone Number *Insurance Provider *Please write N/A or explain if there is no insurance.Are you the patient? *YesNoName of Referring IndividualFirstLastRelationship to the PatientServices RequestedThe patient is seeking... *Counseling/TherapyTesting ServicesMedication ManagementKetamine Therapy (SPRAVATO or Mindbloom)Counseling ServicesIndividual TherapyPlay TherapyCouples CounselingFamily TherapyTesting ServicesADHD EvaluationAutism EvaluationEducational AssessmentPsychological EvaluationNeuropsychological EvaluationPain / Bariatric AssessmentMedication Management ServicesPsychiatric MedicationSuboxone / Addiction TreatmentReason to be seen: *Would you like to add any other information?HIPAA Acknowledgement *I understand and agree to the information below.Clients have certain rights to privacy regarding their protected health information under the HIPAA Act. By checking the box above and submitting this form, the client is acknowledging that they may voluntarily be sharing sensitive information with our practice. While Responsive Centers cannot guarantee confidentially, we will never share any sensitive information with unknown third-party entities or use it for purposes outside of intake and scheduling.Submit
