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Clinical Intake Form

This intake form allows us to securely gather information so that our intake coordination team can help you in the most efficient and sensitive way possible during your appointment.

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Completion of this form is required prior to your appointment. Please contact us if you have any questions or issues completing this form.

Basic Information

Gender Assigned at Birth (required for insurance purposes)
Are you living in the U.S. on a temporary student or work visa?
Please select the therapy format(s) you are interested in
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