Intake Forms & Next Steps

You will be sent intake forms via SimplePractice after you fill out the form below—please check your inbox & junk/spam folder to locate them. These forms help us understand your medical history, symptoms, & goals so we can provide the most effective care possible. By submitting your completed intake forms, we will assume you would like to move forward with the program, & we’ll begin the process of coordinating your care & prescription plan.

Thank you for trusting us with your care. Whether you’re looking for more energy, better sleep, improved mood, or hormone balance—you’re in the right place.

We can’t wait to support you every step of the way.

Name

First Name

Last Name

Email

Are you an existing Emerge Wellness patient currently using any of our services or therapies?

Those already enrolled in Emerge Wellness services will be prioritized for this program.

Preferred Clinic Location

What are the main reasons you're interested in hormone support?

Are you currently experiencing perimenopause or menopause? Have you been dealing with low energy, fatigue, or mood changes? Are sleep issues, low libido, or irregular cycles part of your current concerns? Or are you just exploring your options?

How soon are you hoping to get started with hormone therapy — as soon as possible, within the next month, or are you just looking for more information right now?

Finally, is there anything else you’d like us to know about your goals, symptoms, or health background before we connect?

Emerge Wellness

Women’s Hormone Program

Hormones. Health. Harmony.

Intake Forms & Next Steps

Thank you for trusting us with your care. Whether you’re looking for more energy, better sleep, improved mood, or hormone balance—you’re in the right place.

We can’t wait to support you every step of the way.