Intake Form

Hey beautiful,

I'm honored to work with you!  And look forward to our first appointment.

Please fill in this form. 


If a question doesn't apply leave it blank. 


There are a few questions that do require a response.  They must be completed to submit the questionnaire.

Your answers are confidential because the responses are embedded in this HIPAA-compliant intake and will be recorded in your secure HIPPA-compliant patient portal.

Once you submit the form you'll receive an invitation to create your patient portal, appointment reminders, and a link to the video chat room via email.


Please submit your intake no later than 24-hours before your appointment.  Otherwise, we will have to reschedule.

See you in the video chat room!



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