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INTAKE FORM

Lead Record Type

Embrace U’s therapy programs are designed for adolescents aged 10 to 18, and require a minimum of 10 hours of treatment per week.

Relationship to Patient:

Referring Provider's First Name:

Referring Provider's Last Name:

Referring Provider's Company:

Referring Provider's Phone:

Referring Provider's Email:

Parent/Guardian First Name:

Parent/Guardian Last Name:

Parent/Guardian Phone:

Parent/Guardian Email:

Participant's First Name:

Participant's Last Name:

Date of Birth of Participant:

Location:

I agree to receive text messages and phone calls from Embrace U regarding my inquiry.

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