New Patients

Input client information

Items with an asterisk (*) are required.

    *Completing form for:
    SelfChildOther

    *If "Child" or "Other" were selected above, please provide your name and relationship to client or type "self":

    *Client's First and Last Name:

    *Date of Birth

    *Preferred Phone Number:

    *Can Stepping Stones Wellness Center leave a message when calling the client's preferred phone?

    YesNo

    *Email:

    *Gender:
    FemaleMalePrefer not to say

    *Pronouns:
    He/HimShe/HerThey/ThemOther

    *Marital Status:
    DivorcedDomestic PartnershipMarriedSingleOther

    *Is this appointment request due to a court order or for an Employee Assistance Program (EAP)?:
    YESNO

    *Reason for Seeking Therapy:

    *Prefer In Person or Telehealth:
    In-PersonTelehealthEitherBoth

    *Appointment Availability (check all that apply):
    OpenWeekdaysWeekendsWeekdays 8am-3pmWeekdays 3pm-9pmWeekends 8am-3pmWeekends 3pm-8pmOther

    *Health Insurance Provider:

    *Preferred Therapist or Group: