CONTACT

Please fill out these intake forms within the first week of scheduling your intake. This will allow your clinician time to consult with the referring provider or anyone else with whom you have given permission to share. You may be provided an earlier time if received promptly.

If you would like us to collaborate with a provider, educator, or other member of your service team, parents or adult clients can complete the following form allowing for information exchange:

Release Form

03

Connect

Name

First Name

Last Name

Email

Subject

Message

Checkbox

By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Glori Gray, Psy.D., P.C. harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Yes, I want to submit the form.