Intake for New Client
First Name
Last Name
Email
Phone Number
What are your goals with therapy?
Have you been in therapy before? If so, when was your last session?
Is this for couples or individual therapy?
Describe your ideal therapist
What is your availability (please list days of the week and times). Do you want in person or online?
Are you currently on any medications for mental health reasons? If so, please list.
Submit
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