If you are interested in starting new services and would prefer to complete the intake on your own please submit the form online or print and fax the information in to us,
please select the form below:
Print and FAX the form to 1-866-639-9573 ATTN: Intake Dept.
- Informed Consent for Treatment
- Emergency Information Sheet
- Payments for Healthcare Operations Consent
If you would like us to have contact with another provider (for example, your psychiatrist, primary care physician, etc.), or any other person or agency, complete this form to authorize release of your information:
Note: To download Adobe Acrobat Reader for free, click here.