New Patient Intake Form

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Welcome to Alliance Counseling Works! In order to speed up your onboarding and scheduling process, please take a few minutes to complete this new patient form. After we receive this form, our office will check your insurance benefits (if you have insurance) and will review options for an appointment with your preferred therapist if you selected one. Please allow up to one full business day for a response. Thank you for choosing Alliance Counseling Works. We're Glad You're Here!

Clients First Name *

Clients Last Name *

How did you hear about us? *

Google Search

Social Media (Facebook, Google Ad ect)

From a Friend

Referral from a Doctor

Ketamine Referral (I'm a current patient with Noma)

From your Insurance

Promotional Material ( Flyer, etc)

Event ( Community Fair, Presentation, etc)

Other:

If "Event" or "Other", please tell us what is was.

Primary Contact (Parent/Guardian) First, Last Name * If client is a MINOR*

Contact Email *

Please enter the email you prefer to use for your new patient portal, appointment reminders, and notifications. (For MINORS, use parent/guardian)

Type of Therapy *

Individual

Couples

Family

Please give Clients date of birth. *

YYYY

Preferred Phone Number *

Please enter the phone number you prefer to use appointment reminders and notifications. (For MINORS, use parent/guardian)

Do you want to receive text message (SMS) reminders and communication? *

Yes

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