New Patient Intake Form
Please fill out the information as much as possible in order to process the intake in a timely manner.
Your Information
Your Information
Are you a Sutter Health patient?
Are you a Sutter Health patient?
Referral Source
Referral Source
 
Insurance Information
Insurance Information
What is your reason for seeking help?
Please list any current medications you are taking for psychiatric or emotional difficulties.
Are you currently in treatment?
Are you currently in treatment?
DUE TO A LARGE VOLUME OF NEW PATIENT INQUIRIES, WE MAY NOT BE ABLE TO ACCOMMODATE ALL PATIENTS SEEKING SERVICES IN OUR GROUP. YOU WILL HEAR FROM US WITHIN 48 HOURS WITH INFORMATION ON APPOINTMENT AVAILABILITY.