Pre-Screening Questionnaire
Thank you for your interest in psychotherapy at 2 Hands 2 Help. To request an initial consultation, please fill out the information requested below. Once we receive your request, we will contact you via email or phone to discuss how to proceed. After verifying your financial information and completing a brief phone screen, we will determine whether or not an initial consultation is indicated. Our aim is to serve you as quickly as possible.

Please note that completing the initial consultation does not guarantee placement with an 2 Hands 2 Help therapist. The  initial consultation is free it is an assessment to ascertain if your needs are best met by 2 Hands 2 Help services, or if you would be better served by a referral to another provider.

Unfortunately, 2 Hands 2 Help does not accept insurance at this time. For more information regarding our in-network insurance providers and our sliding scale fees, please visit our fees page.
If you are still interested in services at 2 Hands 2 Help, please fill out the following confidential contact information, and a clinician will contact you.  

Sign in to Google to save your progress. Learn more
First name *
Last name *
Date of Birth *
E-Mail *
Phone number *
Briefly describe why you are seeking therapy. *
Have you had a history or currently experience any of the following? *
Are you currently on psychiatric medication? If so, please include the medication name, dosage, and frequency.
Have you been hospitalized for psychiatric reasons in the past 12 months? If so, please explain (please note if emergency room visit or inpatient hospitilization): *
Do you have insurance? *
Do you have out of network coverage? *
What is your preferred availability? (Please select more than one, if possible.) *
Do you have a preferred clinician in mind? If so, please indicate which clinician below. *
Finally, how did you hear about us? *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy