Contact

Request an Intake

To refer yourself or a family member for a psychological evaluation, please complete this form, reach out to us by phone, or send us an email. Psychological evaluations are available for individuals ages 8 through 55. We are not currently accepting new therapy clients.

As a small practice that operates without administrative support, please be aware that it may take time for one of our psychologists to get in touch with you to arrange your intake session.

We understand the importance of privacy and confidentiality. Rest assured that any information you share with us will be treated with the utmost confidentiality and handled in accordance with professional and legal guidelines.

Providers: Please use the provider referral form.

Client's Legal Name

First Name

Last Name

Client's Preferred Name

First Name

Last Name

Client's Pronouns

Client's Gender Identity

Client's Assigned Sex at Birth

Client's Age

must be between the ages of 8-55 for testing

Parent/ Guardian #1 Name

First Name

Last Name

Parent/ Guardian #2 Name

First Name

Last Name

Parent/ Guardian #3 Name

First Name

Last Name

Parent/ Guardian #4 Name

First Name

Last Name

Email

best email to reach the Client (if they are 18 or older) or the parent/ guardian

Phone

Best number to reach the Client (if they are 18 or older) or the parent/ guardian

(###)

###

####

Is it okay to leave a detailed voicemail?

Yes

No

Insurance

Do you plan to use insurance to cover services?

Yes

No

Insurance

What insurance do you have?

Reason for Referral

Provide a brief description of why you are seeking our services at this time.

Preference for Provider

Do you have a preference for which psychologist you see?

Request an Intake

Providers: Please use the provider referral form.

Location

Hours