Forms

Please print and fill out each form and bring to your first appointment.

 Intake Form

 Release Form

 Responsibilities of Provider

 Consent to Treatment

Get In Touch

Contact me to see if I may be a good fit.

If this is a medical emergency, please call 911.

We highly respect and safeguard your privacy and will never disclose your email address and message to anyone. You acknowledge that the contents of this form will be sent via email and will be stored on servers located in the United States, and understand that you should not use it to provide any personal health information.

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My Office

267 Willimantic Rd. Suite 5
Chaplin, CT 06235
(860) 391-7263