Intake Form

Request an intake form

After you complete this intake form (with a final fit check) you can expect to receive a set of intake forms within two business days.

Name
Are you located in Arizona?
Does tele-psychiatry work for you?
Are you good with private pay?
($600 for the initial session / $375 for a standard 50-minute session / $300 for a abbreviated 25-minute session)
Which of the following do you resonate with?