Please click here to download an Adobe Acrobat version (PDF) of the Intake Form.
From your computer:
1. Open the file
2. Print it to your printer
3. Fill out both pages. Please enter your full legal name that matches your government-issued ID (e.g. Driver's License).
4. Bring both pages to your first appointment
Howard Northrup MA 35627
152 N. Harbor City Blvd, Suite 100, Melbourne, FL MM38293
950 N. Cocoa Blvd., Suite 107, Cocoa, FL MM12631