Substance Abuse Appointment

Name *
Name
Phone *
Phone
Preferred Day *
Preferred Time *
Location *
Please add any additional information
Please Read *
Please note that you are waiving your right to confidentiality when communicating electronically. This form is confidential and is intended solely for the use of the individual or entity to which it is addressed. This communication may contain material protected by HIPAA legislation (45 CFR, Parts 160 & 164). Electronic communication does not imply a therapy contract and until client paperwork and in-person intake is complete, New Perspectives, LLC assumes no therapeutic responsibility for anyone with whom we exchange e-mails.