Trauma Recovery Practice Intake form

Trauma Recovery Practice Intake

This form helps us understand your needs so we can match you with the right clinician and follow up about next steps.

Trauma Recovery Practice Intake Form

Provide your information so we can schedule your first conversation.

First Name

Last Name

Phone

Town of Residence

Preferred Language

How should we contact you?

If you call me and I do not answer, you have my permission to leave me a voicemail If you call me and I do not answer, please do not leave me a voicemail

Are you 18 years old or older? (Required for care at the Trauma Recovery Practice)

I am 18 years old or older.

Are you on a HUSKY insurance plan? (Required for care at the Trauma Recovery Practice)

I am on a HUSKY insurance plan.

Please briefly describe your request for services

Please select the option that applies to you

I am the client I am submitting this for a client

Trauma Recovery Practice Fax Number: 203-658-6259

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