Intake and Service Option Form (June 1, 2026)

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NOTE:

  • All boxes on the form must be completed (even for returning clients), as we require this information to understand your needs and to set up an appointment. Incomplete forms will be returned for completion.

  • Please do not exceed the box capacity, as it makes the form unreadable on our end. If you need more space for some boxes, write “see Additional Health Information Form,” then complete the “Additional Health Information Form” here.

  • Please avoid using ALL CAPS when completing forms.

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