New Patient Intake & Appointment Request — Kickoff intake form (public) for Health Care / Therapy. Standalone version — a hosted mini landing page (an embeddable twin is also available).

A few details so we can match you with the right provider and find a time that works. This takes about five minutes and is for scheduling only — not a medical emergency line.

What it collects (by section):

• About you — First name [short text]; Last name [short text]; Email address [short text]; Patient Role (health) [dropdown: Patient/Client / Parent/Guardian / Caregiver / Partner/Family / Referral coordinator / …].
• What you’re looking for — Service Interest (health) [multi-select: Individual therapy / Couples therapy / Family therapy / Group therapy / Psychiatry/Medication mgmt / …]; Appointment Type Requested [dropdown: Free consult / Intake/New / Follow-up / Second opinion / Urgent fit-in (if available)]; Telehealth vs In-Person Preference [dropdown: In-person / Telehealth / Hybrid / No preference]; Clinician Gender Preference [dropdown: No preference / Female / Male / Non-binary / Prefer not to say / …]; Preferred Session Language (health) [short text].
• When works for you — Preferred Session Days (health) [multi-select: Mon / Tue / Wed / Thu / Fri / …]; Preferred Time Blocks (health) [dropdown: Early morning / Morning / Afternoon / Evening / Weekends only / …]; Earliest Start Date (health) [date]; Waitlist Willingness [choice: Yes / No].
• How we can help most — Topics to Focus On (self-reported) [multi-select: Stress management / Relationships / Grief/Loss / Life transitions / Sleep routines / …]; Health/Therapy Notes (client-specific) [long text].

Required: Email address, Patient Role (health) (kept low-friction).

Form type: Kickoff intake (in), public. Niche: Health Care / Therapy. Deployment: standalone.

Best for / surface when: A therapy or wellness practice taking new-patient appointment requests — capturing who the care is for, the service and visit type wanted, telehealth/in-person and clinician preferences, availability, and waitlist willingness, with no insurance IDs, SSNs, or clinical PHI collected on the public page.