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Please follow these instructions when completing the form:
- All boxes must be completed (even for returning clients), as we require this information to understand your needs and schedule an appointment. If information is missing, we will return the form for completion. NOTE: This form is not an assessment.
- If you are a returning client, please do not mark “see previous Intake and Service Option Form,” as this form is the basis for current services that will be provided.
- Please keep your answers within the box capacity, as excess text will be truncated. If you need more space to provide health information, please write “see Additional Health Information Form” in the box that is too small, and then also complete the “Additional Health Information Form” available here.
- Please remember to check off the service(s) you are requesting.
- Please avoid using ALL CAPS or all lowercase.
Completing the form for a minor: The last page of the Intake and Service Option Form for a minor (youth under the age of 19 years) needs to be signed by the youth’s parent or guardian.
Confirmation: After you click “Submit” at the end of the form, you will immediately see a confirmation message on the screen. It will provide a link to edit your submission (including adding lab work) and a separate link to download a copy of the form for your records.
NOTE: Click here to open the full-size Intake and Service Option Form in a separate window to complete your submission. Attempting to complete the form in the preview below may result in errors.
✉️ On your phone? Email this form to yourself to complete later on your computer.