Individual Therapy
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Your Name *
Your Email *
Your Phone Number  *
Your Date of Birth *
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Where are you located? *
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Interested in virtual or in-person sessions? *
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What can we help you accomplish? *
Have you sought therapy in the past? (If so, was there anything negative or positive you experienced in that treatment?) *
Have you ever had mental health emergencies in the past? (Crises such as: panic attacks, debilitating depression, suicidal feelings and/or attempts, any hospitalizations for mental health? If so, how long ago and what was the treatment for it?) *
What time would be best in your schedule to meet for therapy? *
What would be the best style of communication for you? (When speaking with your therapist would a more direct/challenging approach be best or a collaborative/supportive approach?) *
Is there a specific therapist you would prefer to work with? *
Required
Have you had contact/started the intake with one of our team members? *
How did you hear about us? *
Is there anything else you would like us to know about you? Any other questions for us? *
Upon submission, a member of our team will be contacting you.

*Due to the high-sensitivity of spam monitoring by various email providers, please keep an eye on your spam/junk folders for our communication.
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