Therapy Prescreen Form

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Thank you for choosing TK Center for Healing & Wellness. Please answer each question honestly and to the best of your knowledge. Please type “N/A” if the question does not apply to you.

*Please be advised there is a current waitlist for new clients. Upon an opening that fits the availability you list on this form, you will be contacted via EMAIL with a 48hr window to respond.

*If you are experiencing a medical or mental health emergency please call 911 or go to the nearest emergency room.

*Submitting this form is NOT an agreement or start of services*

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Are you completing this form on behalf of yourself or someone else? *

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