Therapy Charlotte LLC
In preparation for your first appointment, please complete the following form. The information you provide here is protected by law and held in strict confidence.
Primary Phone Number
May I leave a message?
May I e-mail you? (Please note: E-mail correspondence is not considered to be a confidential medium of communication)
Name of emergency contact:
Phone number of emergency contact:
How did you hear about Therapy Charlotte?
Referred by a friend
Psychology Today Directory
Areas of Concern: Please check all that help describe your concerns or goals.
Career identity or planning isses
Depression or feeling low
Impulse control issues
Perfectionism or procrastination
Self-esteem or personal growth
Struggling to perform in career
Thoughts of suicide or homicide
In your own words, why are you here today and what do you want to accomplish?
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