A reassuring, calm setting representing the start of care with Ohanacare Solutions

Intake

Begin care, at your pace

This short, privacy-conscious form helps us understand your needs so we can follow up with the right next steps. You do not need a diagnosis or a referral to begin.

Before you begin

If this is a medical or mental health emergency, call 911 or go to the nearest emergency room. This form is not monitored for emergency requests. Please do not submit urgent medical concerns through this form.

Intake request

About you

Full name

Date of birth (optional)

Share only if you are comfortable.

Phone number

Preferred contact method

Who is completing this form?

City

State

About your inquiry

Service of interest

Brief reason for your inquiry

A general summary is enough. Please do not include sensitive medical details here.

Acknowledgments

If this is a medical or mental health emergency, call 911 or go to the nearest emergency room. This website and its forms are not monitored for emergency requests.

Telehealth services require patient consent and may not be appropriate for every situation. A clinician will determine whether telehealth is appropriate based on the individual's needs and location.

I have read the Notice of Privacy Practices and understand how my information may be used, and I agree to be contacted about this request.

Submitting this form does not establish a clinical relationship or guarantee services. Services may be subject to clinical review, eligibility, availability, and location.