Intake form to be filled out prior to first session Please enable JavaScript in your browser to complete this form.Please confirm that you understand that I am no longer taking new patients through insurance only private pay. *YesNoI don't understandName *FirstLastEmail *Questions about how I may help you?PhoneSubmit Dr. Mikol Davis1703 Fifth Street, Suite 101San Rafael, CA 94901Tel: 415-459-1203drmikol@gmail.com