"Dedicated to the work of health and healing."

Application and Referral Forms
For your convenience, you may print Intake Forms and have them completed upon arrival to your first visit. Having your paperwork done prior to your first visit will greatly expedite your check in process. If unable to complete ahead of time, Intake Forms will also be provided at check in the day of your first appointment. If you have any questions about the forms, please ask for assistance from our front desk staff and we will gladly assist you. 
 
Application Packets
ATTENTION: If application is completed in Adobe Reader, you must physically sign all signature pages. Typed signatures are not valid. 
 
Adult Application Packet
Please complete all pages of this application packet. The paperwork must be completed in its entirety prior to an appointment being established. 
 
Please complete all pages of this application packet. The paperwork must be completed in its entirety prior to an appointment being established.
 
Child Application Packet: Ages 4-10
Please complete all pages of this application packet. The paperwork must be completed in its entirety prior to an appointment being established.

Child Application Packet: Ages 11-17
Please complete all pages of this application packet. The paperwork must be completed in its entirety prior to an appointment being established.
 
 
Headwaters ACT Referral
ATTENTION: If application is completed in Adobe Reader, you must physically sign all signature pages. Typed signatures are not valid.
 
Please complete all pages of this application packet. The paperwork must be completed in its entirety prior to the review process. 
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