Intake form

Help us serve you better

Name *

Email address *

What is your age?

What is your gender?

What services are you interested in?

Please select at least one option.

Substance use disorder treatment

Primary care medicine

Psychiatric care

Medication-assisted treatment

Job assistance

Collaboration with sober living houses

Do you have any existing health conditions?

What medications are you currently taking?

How did you hear about us?

Do you have any previous experience with counseling or healthcare services?

What is the best way to contact you?

What is your preferred method of communication?

Are you currently employed?

If employed, what is your occupation?

Additional questions or comments

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Valley Health and Counseling