Wellness Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

At GW Hillel, our mental health externs will offer you up to a year of in-person, or virtual therapy. Each session will be 50 minutes in duration.

Therapy will cost $25 per session, including the intake. However, if this fee is a barrier to treatment based on financial constraints, we are happy to accommodate using a sliding scale fee. This opportunity is a great opportunity to explore issues big or small. We look forward to working with you!

Name

Pronouns

Gender

Race/Ethnicity

Primary Language

Date of Birth

YYYY

Home Address

College Address

Cell Phone

Email Address

Preferred Method Of Contact

Call

Please check all that apply:

I give permission to therapist to leave me a voicemail.

I give permission to therapist to send me a text message.

I give permission to therapist to send me an email.

Emergency Contact (please leave name, phone, & email)

Referral Source (please leave name & phone)

Reason for Referral: Why are you seeking therapy?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Hillel at the George Washington University.

Does this form look suspicious? Report

Forms