Fields marked with * are required.
Personal Information
Your basic contact and demographic details
Contact Information
Address
Emergency Contact
Reason for Visit & Current Symptoms
Help us understand what you're experiencing
Symptoms Experienced in the Past 2–4 Weeks
Life Impact Areas
Safety Screening
These questions help us ensure your safety — answers are confidential
Important: If you are currently in crisis or having thoughts of harming yourself or others, please call 988 (Suicide & Crisis Lifeline) immediately or dial 911. Do not wait to submit this form.
Yes
No
Yes
No
Yes
No
Yes
No
Psychiatric History
Previous mental health treatment and medications
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Medical History
Conditions, allergies, and surgeries — ensures safe treatment
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Lifestyle & Social History
Lifestyle, family history, and social situation
Yes
No
Yes
No
Yes
No
Yes
No
Provider Preferences & Scheduling
Help us match you with the right provider
Yes
No
Either
Yes
No
Either
Yes
No
⚖️ Agreement to Arbitration — Medical and Behavioral Health Malpractice Claims
It is understood that any dispute as to medical malpractice — that is, as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered — will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings.
Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Arbitration under this agreement shall be conducted through JAMS, pursuant to its applicable rules and procedures.
JAMS arbitration is a formal and binding adjudication, and determinations issued by the arbitrator will be enforceable as a judgment. The ability to challenge or overturn an arbitration award is limited under California law. This arbitration agreement applies to all future services unless rescinded in writing within 30 days. For minors, the signature of a parent or legal guardian is binding and may not later be disaffirmed.
Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Arbitration under this agreement shall be conducted through JAMS, pursuant to its applicable rules and procedures.
JAMS arbitration is a formal and binding adjudication, and determinations issued by the arbitrator will be enforceable as a judgment. The ability to challenge or overturn an arbitration award is limited under California law. This arbitration agreement applies to all future services unless rescinded in writing within 30 days. For minors, the signature of a parent or legal guardian is binding and may not later be disaffirmed.
⚠️ NOTICE: BY SIGNING THIS FORM YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.
I have read and understand the Arbitration Agreement. I agree to resolve any medical malpractice disputes through binding arbitration and waive my right to a jury trial.
Signature & Acknowledgment
By signing below, I confirm that I have read, understood, and agree to all terms of this consent form. I confirm that all information provided in this intake form is accurate and complete to the best of my knowledge.
Sign here with your mouse or finger →