New Client Intake Form: Individual Therapy, Couple Therapy, & EF Coaching
Thank you for your interest in our services! 

Please complete this form to initiate the individual therapy, couple therapy, or executive function coaching process with one of our clinicians. 

If a therapist has availability that matches your preferences, we’ll contact you to help you schedule an appointment and get your file set up with us.  

For our clinicians who currently have full caseloads, we will use this information to add you to a waitlist. We will contact you as soon as an opening becomes available. Please note that we are unable to provide an estimated wait time or guarantee when an appointment will become available.

This form takes approximately 5 minutes to complete. 

If you prefer to complete this form over the phone, please call (437) 783-5210‬ and leave a voicemail with your callback availability. A member of our administrative team will be in touch.

Your information will be stored securely with our administrative team while we work to connect you with the right clinician. Once an appointment is booked, the relevant information will be added to your clinical chart to help support your care.
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Name

(Please note - you can use whatever name you prefer here for privacy reasons, but we will need your Full Legal Name at the time of booking)
 *
Email Address *
Phone Number
Pronouns 
Preferred method of contact  *
Required
What service are you interested in? If you are unsure which service may be right for you, please visit our website's therapy page for more information.  *
Required
  Are you looking for:   *
General Availability
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
How often are you hoping to meet with your therapist?
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Are there things that matter to you about a clinician's style or approach? 

(e.g. Do you prefer a structured approach, or a more client-directed approach? A solution-focused approach or a more exploratory approach? Homework or no homework?...)

What are you hoping to get out of therapy?

Is there anything else you would like us to know? 

(For example, any accessibility needs, language or communication preferences, accommodations, or anything else we can consider to help make your experience with us more comfortable and accessible.)  
 Are you hoping to work with a specific clinician?  
If your preferred clinician is unavailable for an extended period, would you like us to:  
Clear selection

How did you hear about Accord Psychology?

Sometimes we may need a little more information to determine whether one of our clinicians would be a good fit. Are you comfortable with us contacting you if we have follow-up questions?   *
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