Appointments

Consent*

I agree to the privacy policy.

By completing this form, you consent to sharing your information with our intake staff and the therapist to whom you may be referred. This form is confidential and will only be read by authorized staff to ensure we match you with the best therapist for your needs. Please provide as much detail as you are comfortable with, knowing that your information will be kept private and secure by our HIPAA-compliant team.

Your Name*

First Last

What type of therapy are you requesting?

Individual Therapy
Couples Therapy
Therapy for a child or children
Other
Unknown

What times are you available for therapy?

Check as many as apply. This helps us determine if a therapist's schedule fits with yours.

Morning
Late Morning
Early Afternoon
Late Afternoon
Evening

Who would you like to work with?

Check as many as apply.

Email*

Your email will be kept confidential, kept only on our practice records, and only used for purposes of contacting you.

Phone*

Your phone number will be kept private and is for solely for purposes of contacting you about an appointment.

How would you prefer to be contacted?*

We will contact you as soon as possible. Let us know what is the best way to contact you. Thanks!

Your Message:*

Feel free to ask any questions or let us know any details that would help us get you the best help you need. The more information the better!

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Email

This field is for validation purposes and should be left unchanged.

Schedule Your Appointment

Hours

Phone

801-341-1919

E-mail

Address:

1022 N Redwood Road Suite 202 Saratoga Springs, UT 84045