Intake

Patient Name *

First Name

Last Name

Patient Date of Birth *

MM

DD

YYYY

Contact Phone (Cell Preferred) *

(###)

###

####

Patient Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Where do you prefer to been seen?

Oakland Office

Cumberland Office

Hagerstown Office

VIRTUAL ONLY (MD residents)

Which provider(s) do you prefer?

NO PREFERENCE

James Lukas, CRNP

Kelly Neff, CRNP

Myranda Spigler, CRNP

Regina Palmer, LCPC

Nasrine Nikpora, LCPC

Leslie Henriquez, LCSW-C

Are you planning to cash pay or use insurance? *

I will use my insurance

I am paying cash