Request an Intake

Not for emergencies

This form is not monitored in real time and is not for urgent situations. If you are experiencing a mental health emergency or thoughts of harming yourself or others, please call 911 or dial 988 for the Suicide & Crisis Lifeline right away.

What happens next

After you submit this form, a member of our office will reach out by phone to confirm your intake appointment, verify insurance, and answer any questions.

A note on privacy: this form sends your responses to our office by email rather than a secure patient portal. Please keep the description of what brings you in brief and general — our team will gather full clinical details with you directly, by phone or at your visit.

Already an established patient? Please call our office directly at (602) 730-4875 for follow-up appointments — this form is for new patient intakes only.

Full name *

Date of birth

Phone number *

Email address *

Preferred visit type *

In-person Telehealth No preference

Insurance *

We currently accept Aetna and United Healthcare only.

Briefly, what brings you in? *

Preferred days or times (optional)

Intake request received

Thank you — our office will be in touch to verify your appointment and insurance.

If this is a medical emergency, call 911 or go to your nearest emergency room. For a mental health crisis, call or text 988 to reach the Suicide & Crisis Lifeline, available 24/7. This website is for general information only, does not constitute medical advice, and does not establish a provider-patient relationship.

Not for emergencies

What happens next

Intake request received