STUDENT INTAKE FORM

Student Intake

Start Student Telehealth Intake

Quick pre-intake to help our clinic route you correctly. You will be taken to the Request Services page next.

Student full name

Phone

Florida county (optional)

School or district (optional)

Age range

What are you looking for today?

Medication is prescribed only when clinically appropriate after evaluation by a licensed provider.

Anything you want the clinic to know?

Contact the clinic

If this is an emergency, call 911 or go to the nearest ER.

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