Pre-Registration FormPlease complete the following form to notify us about your need for treatment. Appointments are not provided until all Patient Intake Forms are completed, copies of your insurance card front and back and a copy of your license is submitted. When you complete this pre-registration form an email will be sent to you with instructions on where to submit your intake forms. Once the Front Desk receives these documents, they will reach out to you and schedule an appointment. Thank you!Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Date Format: MM slash DD slash YYYY How did you hear about us?*Friend or FamilyPrevious PatientPrimary DoctorSMHWI WebsiteGoogleFacebookLinkedInPsychology TodayOtherWho referred you?*Primary Medical Provider*Current Insurance*Secondary InsurancePhone*Email* Preferred Date* Date Format: MM slash DD slash YYYY Preferred TimeMorningAfternoonEveningNature of VisitCAPTCHANameThis field is for validation purposes and should be left unchanged.