Intake Form

Enter information for an appointment. We will contact you via EMAIL.
(If submitting more than 1 intake, please use a unique email address for each.)

Once you hit submit, your confirmation will generate at the top of this page.

We value your time, your trust, and your privacy.  We aim to review your concerns within 2-4 business days; please ensure your email and phone are correct.  While we process your information, please contact 911 in the case of emergency (thoughts of self harm, suicide, or harm to others.)  We will contact you via EMAIL.


Thank you

Phone: 682-200-1744

Secure Fax: 682-478-5487


Main Office: 1001 12th Ave, Suite 174

Fort Worth, TX 76104

Southlake Office : 410 N Carroll Ave, Suite 190

Southlake, TX 76092