Client Health Intake Form
You can use this form to provide general information about yourself or family member
Autism PANS & PANDA
Please use this form to provide detailed information on your family member diagnosed with PANS or PANDAS
General Women's Health Intake Form
Please use this form to provide specialist information required by the women's health program
If you are intrested in Technology based Services then use this form
Directions for Use
Click on the image of the form that most applies to you, and then it will automatically download the form. Complete the form either online or with a black or blue pen.
You may then bring it with you for your first appointment or you may send it to us securely at email@example.com
Messages are encrypted at all times
Messages are stored on ProtonMail servers in encrypted format. They are also transmitted in encrypted format between our servers and user devices. Messages between ProtonMail users are also transmitted in encrypted form within our secure server network. Because data is encrypted at all steps, the risk of message interception is largely eliminated.