Wellness Intake Form

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At GW Hillel Wellness, our Mental Health Externs will offer you short term therapy for 8-10 sessions. 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. 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

Text

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?

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