Looking to schedule an appointment? - Responsive Centers for Psychology and Learning

General Information

Patient's Name *

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Last

Patient's Date of Birth *

Email *

Phone Number *

Do you agree to receive SMS messages at the phone number listed above?

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By checking this box, you consent to receive text messages from Responsive Centers regarding your inquiries, orders, or services. You may opt-out at any time by replying STOP. For assistance, text HELP or review our Privacy Policy: https://responsivecenters.com/privacy-policy/. Message and data rates may apply. Messaging frequency may vary. By checking this box, you acknowledge that you have read and understood our Privacy Policy and the terms and conditions written here.

Insurance Provider *

Please write N/A or explain if there is no insurance.

Are you the patient? *

Name of Referring Individual

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Last

Relationship to the Patient

Services Requested

The patient is seeking... *

Counseling/Therapy
Testing Services
Medication Management
Ketamine Therapy (SPRAVATO or Mindbloom)

Counseling Services

Individual Therapy
Play Therapy
Couples Counseling
Family Therapy

Testing Services

Medication Management Services

Psychiatric Medication
Suboxone / Addiction Treatment

Reason to be seen: *

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How did you hear about us? *

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. Please review our complete Privacy Policy here: https://responsivecenters.com/privacy-policy/.