THIS REGISTRATION IS NOT FOR EMERGENCIES. IF YOU HAVE AN EMERGENCY, CALL 911 OR VISIT YOUR NEAREST EMERGENCY ROOM.

Please provide the following information as completely as possible. Before we contact you to schedule your first appointment, we must first verify your insurance benefits (if you are using insurance), determine your copays and deductibles, and identify a clinician who fits your needs. This may take several days, so please be patient.

We will contact you by email, so please check your inbox frequently.

If you are completing this only to sign/re-sign the Client-Provider Agreement or to provide new insurance information, complete items 1-15 and then skip to the appropriate items. Indicate in item 15 that is the reason you are completing the form.
Client Information:
If you want us to notify your primary care doctor, please provide the doctor's name and fax number:
If client is under 16, please provide the following:
Health Insurance Information (If you are not using insurance, check box 21 and skip to #39). Incomplete or missing information will delay your registration:
If client is not the policy holder:
Client-Provider Agreement: