Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Birthday
*
MM
DD
YYYY
Main Areas of Concern
*
Please choose the areas of concern that you would like to address in therapy. This will help us connect you with the Therapist who best matches your needs.
Where do you prefer to see your therapist?
In-person
Online
Open to either
What are specific upcoming times this week and next that you can see someone?
In general, what is your weekly availability for sessions (times and days)?
Please include anything else we should know. This will help us to match you with a therapist. Take some time doing this as a real person will review your case and use the information here to try to match you with the very best therapist.
Have you have been recently hospitalized for mental health issues or hospitalized in the past?
Are you currently feeling like you could hurt yourself or someone else?
Have you had any suicide attempts in the past?
Are you currently experiencing abuse and/or domestic violence in your home?
Are there any other providers involved in supporting your mental health journey ( social services, legal support, nutritionists, prescribers, psychiatrists, or doctors)?
If you are filling this form out for a child please let us know this and provide their age and their contact information if they are 12-17 (email and phone number).
If you are a parent filing out this form for your child, are you in a high conflict divorce, custody process, and/or have a high conflict coparenting relationship with your child's parent?
If you are filling out this form for yourself and a partner and requesting couples therapy, please provide their name (email and phone number.)
If you are a parent filling this out for your child, is your child adopted or a foster child?
If you are a parent filling this out for your child, what is your birthday for insurance billing purposes?
