Schedule an Intake

Begin Your Journey to Wellness

Please complete this confidential, HIPAA-protected intake form as the first step in scheduling your initial appointment. Our office coordinator will contact you within one business day of submission.

Client Information

Are you a new or returning client?

New client

Returning client

Full Legal Name

Preferred Name

Spouse's Name (for couples therapy only)

Guardian’s Contact Information (for minors only)

Emergency Contact Name and Phone Number

Date of Birth

Gender Assigned at Birth

Gender Identity

Pronouns

Address

Country/Region

Address

City

Zip / Postal code

Email Address

Phone Number

Insurance Information

How will you pay for sessions?

Insurance

Self-pay (no insurance)

Primary Insurance Provider

Primary Insurance Member ID

Other Insurance Provider (if applicable)

Other Insurance Member ID (if applicable)

Therapy Preferences

Do you prefer in-person or virtual therapy sessions?

Do you have any specific preferences for your therapy (e.g., therapist style, areas of focus)?

Would you like to receive communication via email and text messages? (e.g., appointment reminders, important updates)

We'd love to know — how did you hear about us?

Base Behavioral Health

Schedule an Intake

Begin Your Journey to Wellness

Client Information

Insurance Information

Therapy Preferences

Base Behavioral Health

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