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New Client / Waitlist Questionnaire
Please complete this form to begin counseling or join my waitlist. I will do my best to contact you with my availability when I have an opening or to offer referrals when I cannot take on new clients.
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Email
*
Your email
Confirm email address
*
Your answer
Your name
*
Your answer
Your child's name
*
Your answer
Your child's age
*
Your answer
Reason for seeking help
*
Your answer
What type of service are you looking for?
*
Individual Counseling
Play Therapy
Group Therapy
Other:
Required
How did you find me?
Your answer
What is your availability for appointments?
*
Midday appointment
Afternoon or evening appointment only
Available for whatever time is open
Other:
If I do not have immediate availability, would you like to be placed on the waitlist?
*
Yes
No
Would you like referrals if I am unable to meet with you immediately?
*
Yes
No
What additional information would you like me to know?
Your answer
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