New Client Intake Form

We look forward to serving you. We will review your information, and contact you regarding our availability for accepting new patients within 48 hours. Note, submission of this form does not guarantee service, as we may be unable to take on new patients at this time.
First Name*
Last Name*
Your Email*
- I consent to receive email regarding appointments, billing and other non-clinical information from Grey Matters Mental Health Clinic, PLLC.
Your Phone Number*
- I consent to receive text regarding appointments, billing and other non-clinical information from Grey Matters Mental Health Clinic, PLLC.
What's going on?*
(i.e., Depression, Anxiety, PTSD, etc)
What medications do you take?*
Medication / Dose / Frequency
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