NEW CLIENT FORM 🌱

Welcome to NOT BROKEN THERAPY!

Big deep breath—you made it here. That alone is a big freaking deal.

This form covers the basics: your availability, out-of-network info, and scheduling preferences. It helps me get a clear picture so I can make sure we're a good fit and get things rolling as smoothly as possible.

I know reaching out for therapy can feel like a whole thing. It’s vulnerable, sometimes awkward, and maybe even a little scary. But you’re here, and that tells me a lot already.

Thanks for being here. I’m really glad you are.

Let’s do this! 

Sign in to Google to save your progress. Learn more
Client's First and Last Name *
Your name (If you're submitting a form on behalf of a client) *
Client Phone Number *
Client Email Address *
Client Date of Birth *
MM
/
DD
/
YYYY
Client Gender at Birth *
Client Pronouns
Street Address *
City, State, and Zip Code *
What time preference do you have for our sessions? *
Required
What day preference do you have for your appointments? *
Required
What are you looking for support with? *
Required
What’s been going on that made you think, “Maybe I should go to therapy”? (Don't overthink this. Just a vague snapshot is totally fine 🫠) *
In the past have you had suicidal thoughts or attempts? *
Are you currently having suicidal thoughts? *
Will you be using your insurance to request out-of-network reimbursement? *
If you don't know what I'm talking about, click here! ➡️ Check Your OON Benefits Here
Required
How did you hear about me? (Please list Name/Place so we can thank them!)
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Not Broken Therapy.

Does this form look suspicious? Report

Google Forms