We're here for your mental health journey.Please complete this form if you are looking to schedule an initial appointment or receive more information about our services. Our caring staff will respond to inquiries during operating hours as soon as possible.Please enable JavaScript in your browser to complete this form.Client InformationClient Name *FirstLastClient Date of BirthEmail *Phone Number *Insurance ProviderName of Individual ReferringFirstLastThis person may be a healthcare professional, school administrator, parent/guardian, or any individual who is completing the form on behalf of the client. Relationship to ClientServices DesiredSeeking *Counseling ServicesTesting ServicesMedication Management ServicesCounselingIndividual TherapyPlay TherapyCouples CounselingFamily TherapyTestingADHD EvaluationAutism EvaluationEducational AssessmentPsychological EvaluationNeuropsychological EvaluationPain / Bariatric AssessmentMed ManagementPsychiatric MedicationSuboxone / Addiction TreatmentMessageHIPAA 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 personal information with third parties or use it for purposes outside of scheduling and intake.Submit
