Intake Appointment Request - Yana Tallon-Hicks, Brattleboro, VT
Welcome!

This form is for new intake appointment requests with Yana in the Brattleboro, VT office only!

Please fill out this form to request a new intake appointment with Yana Tallon-Hicks, MA, individual and relationships therapist in her Brattleboro, VT office. This office is located in the Soma Wellness Center in downtown Brattleboro at 167 Main Street, Suite 312.

Yana sees clients in Brattleboro on Mondays, Tuesdays, and Wednesdays. If you'd like to request an intake to see Yana at the Couples Center of the Pioneer Valley in downtown Northampton, Ma, please instead visit https://pioneervalleycouplestherapy.com/ to do so.

**** CONFIDENTIALITY NOTICE ****

Please note: GoogleDocs, GoogleForms, and/or email are not secure or confidential ways to communicate. Never send sensitive or confidential information via these formats unless you have carefully considered the risks in doing so.

For this reason, the majority of your sensitive, personal, and/or identifying information will be gathered in-person via physical intake paperwork at your scheduled intake appointment. Please only use this GoogleForm to request an intake appointment if you have considered the confidentiality risks of doing so.

Otherwise, please request an intake appointment in the Brattleboro office via phone by calling Yana directly at 413-813-8828.

Yana can be reached by cell phone or email to discuss scheduling and other logistical details within business hours. However, therapeutic content is not best discussed through these channels and should be discussed during session.

I offer non-crisis therapeutic support and options. If there is a mental health crisis and you require immediate assistance:

Health Care and Rehabilitation Services of Southeastern Vermont (HCRS) offers local 24/7 mental health crisis support at 1-800-622-4235 and the National Suicide Prevention Lifeline can be reached 24/7 at (800) 273-8255.

Your first name *
Further personal information like your last name will be collected in-person during our first intake session.
Your answer
Your pronouns (optional):
Your answer
Your partner/s' first name/s (if applicable)
Your answer
Your partner/s pronouns (if applicable)
Your answer
Your email: *
Please leave the email address/es that you'd like me to use to confirm your appointment.
Your answer
Your phone number (optional):
Please only leave your phone number if you would prefer I contact you via phone to confirm your intake.
Your answer
Type of therapy you're seeking (check all options that apply): *
Please note that I do not accept any insurances. All appointments can be paid via cash, check, or via PayPal. There are a limited amount of sliding-scale fees available for clients adversely affected by socioeconomic factors. Please indicate if you'd like to be considered for a sliding-scale appointment below. If you are able to pay fees in full, you will be creating more space for others to receive sliding scale rates.
Required
Please check off any/all general descriptors of the nature of your reasons for seeking therapy: *
Required
Please check off any/all appointment slots that might work for you & your schedule *
Please note that not all of these appointment times may be currently open or available as my schedule can shift rapidly. Don't see a time that works for you? Please indicate this below and we can discuss what we can make work over email.
Required
Are you seeking a weekly appointment or bi-weekly appointment? *
Do you require any accommodations in order for your office visit to be accessible to you and/or your partner/s? If so, please list.
The Soma Wellness Center building includes an elevator and a gender-neutral bathroom. There are no stairs between the elevator and the office space in which therapy appointments are held. Yana has a small, friendly dog (Brewster) who occasionally joins her appointments in the office. Please indicate if allergies or fears require that the dog is not present for your appointments.
Your answer
Anything else that's important for me to know about your intake?
Your answer
Please check here to confirm that you are 18 years old or older. *
Minors can be seen for therapy on a case-by-case basis with required parental/guardian permissions. Please contact Yana directly at y.tallonhicks@gmail.com to discuss therapy as a minor further.
Required
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