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Client Intake Form and Insurance Verification
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Email
*
Your email
Name
*
Your answer
We only conduct telemental health in California. Is CA where you reside?
*
Yes
No
Required
Where did you find out about our services?
Your answer
Are you apart of the Joy Of Medicine Program?
Yes
No
Clear selection
Therapy Modality preference:
*
Online
In-Person
Either is fine with me
Age
*
Your answer
Gender Identity
*
Your answer
Gender Preference Of Therapist
*
Your answer
If gender preference of therapist isn't available would you be open to trying someone else?
*
Yes
No
Have you ever been in therapy before?
Yes
No
Maybe
Other:
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What are you struggling with?
*
Anorexia or Restrictive Eating
Bulimia or Purging
Binge Eating Disorder
OCD
LGBTQ+ Support
Anxiety
Psychosis/Voice Hearing/Hallucinations
Trauma/PTSD
Depression
Bipolar I
Bipolar II
Stress
Grief And Loss
Personality Disorders
Relationships
Gender Identity
Substance Use
History of Suicide Attempts
Current Suicidal Ideation
Other:
Required
Have you been formally diagnosed with a mental health condition?
*
Your answer
Anything else you would like us to know in order to best match you with an available therapist (i.e., cultural or diversity considerations, other information)?
Your answer
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