New Patient Intake Form
I strongly recommend making an advanced reservation to guarantee my time with you as I do have busy schedules and to avoid disappointments assisting you in planning a program that best suits your needs.
Please complete this form and be honest with yourself. Some of the questions that follow may seem unrelated to your condition, BUT they may play a major role in diagnosis and treatment. All information is strictly confidential. No information is disclosed or shared without your written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose other than the fields marked with an asterisk *. Just click “SUBMIT” at the bottom of the page and we will receive your information securely. Please note I am NOT able to accommodate walk in appointments and you do not have any until you receive confirmation from me.
All information is held in strictest confidence.