New Client Inquiry 2025

New Client Inquiry Form

Thank you for reaching out, we look forward to working with you.
Getting Started

1) Complete this online form and we will match you with a therapist and reach out by phone, email or text to introduce the therapist and schedule your intake appointment.

or

2) If you have questions about our practice, therapists, or would like to schedule an information call, please complete the form and then use the calendar at the bottom to schedule a convenient time. We will call you then!

Thank You!
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Name

First NameLast Name
Client Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Age:
Administrative Sex (gender at birth)
Client Employer
School year:
Grade Level
School/District (if a student)
Parent/Contact Name if different than client

First NameLast Name
Relationship to Client
Phone Number

Area CodePhone Number
Intake appointment preference: (please mark all that apply)
Best way for us to contact you to schedule an intake appointment:
Text, Email, or Call with best day and time.
Email
example@example.com
Please sign me up for the CORE Connection Newsletter (typically sent once a month). (Current clients will be notified of important practice updates by email or through the portal.)
Insurance:

Other
Please share your concerns?

Other
Services you are seeking?

Other
Request for a therapist, if available:
If requested therapist does not have current availability are you open to working with another one of our therapists:
Do you prefer telehealth appointments or in-office?
What is the best way to contact you to schedule an intake appointment ?

Other

Therapy appointment time availability:

Rows	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning 9, 10, 11 am
Early Afternoon Noon, 1, 2, or 3 pm
Late Afternoon 4, 5 or 6 pm
Evening 7 or 8 pm

Please share any other information about schedule and availability.
Please share how you found us:
Name of person who referred you to us:
Name of who referred you
Schedule an information call:
Other Client information to Share:
Completed by:

First NameLast Name
Should be Empty:

New Client Inquiry Form