Please complete all sections before your first appointment
Select the service that best matches what you're looking for. If you're unsure, we will help guide you.
If completing for a minor, enter the child's information here
Tell us how we can best support you or your family
Check all that apply
Past and current information to provide clinical context
Required for all patients. For telehealth, your current physical address is required for emergency dispatch.
All communication with other providers requires written authorization
Please read each section carefully. All items must be acknowledged before submitting.
I consent to psychological assessment, therapy, consultation, and behavioral health services provided by Renewed Thought. I understand that I am an active participant in this process.
I acknowledge that I have been provided with or given the opportunity to review the HIPAA Notice of Privacy Practices, which describes how my protected health information may be used.
I understand that payment is due at the time of service. Renewed Thought is an out-of-network provider. Cancellations require 48-hour notice to avoid a full-session fee.
I understand my right to receive a Good Faith Estimate explaining how much my medical care will cost before I receive services, per the No Surprises Act.
I consent to telehealth services. I agree to be in a private location with a secure connection. I understand sessions will not be recorded without my written consent.
I certify that all information provided in this intake form is accurate and complete to the best of my knowledge.
Thank you for completing your intake form. Your information has been securely submitted.
A member of our team will contact you within 1–2 business days to confirm your appointment.
