Welcome to Brave Mental Health Practice!
Thank you for considering Brave Counseling & Wellness for your mental health needs. Your well-being is our top priority. Please take a few minutes to complete this form to help us understand your unique situation and provide you with the best possible care.

Welcome to Brave Counseling and Wellness!

Brave is a multidisciplinary & multispecialty practice. What does this mean for you? Our practice provides coaching, counseling and medication management. We collaborate as a team to help you reach your goal and heal. At Brave, we know the best predictor of your success in therapy is the connection you have with your therapist. It's ALL about finding someone who is a great fit for you! In this brief questionnaire, we are going to gather a little information about your current struggles, goals for therapy, and even your preferred days and times for appointments!
Sign in to Google to save your progress. Learn more
Date *
MM
/
DD
/
YYYY
Demographic & Contact Information
Client's Contact Information
Legal Name of Client (First and Last):
 *
Preferred Name
Pronouns
Date of Birth (DOB):
 *
MM
/
DD
/
YYYY
Phone Number *
Email Address *
Street Address: *
City *
State *
Zip Code *
What is your preferred method of contact?
 *
Required
Parent or Guardian's Contact Information
Required: For clients under the age of 18 or those requiring guardian consent, please kindly provide the contact information of your parent or guardian. We want to ensure that we have all the relevant information to support you and make your experience at Brave is as smooth as possible.

Optional: We understand that many young adults are still covered under their parents' health insurance or rely on their support to access mental health treatment. Providing your parent or guardian's contact information is essential for coordinating benefits checks, health insurance verification, and collecting credit cards and payment. This helps us ensure a smooth process, especially for those on their parents' health insurance or receiving financial support. Rest assured, your personal and financial information will be treated with the utmost confidentiality. We are here to support your mental health journey and look forward to providing you with exceptional care.
Legal Name of Parent or Guardian:
Phone number
Email Address
Spouse or Partner Contact Information
Required: Please provide your Spouse or Partner's contact information if applicable. This information is required for couples, family clients, or any child under 18 years old who may require guardian consent. Rest assured, your Spouse or Partner's information will be treated with confidentiality and used solely for the purpose of providing comprehensive and tailored care.

Optional: If you are not seeking the services about, you may still wish to include your Partner's contact information. Some clients may choose to include it if they wish to involve their significant other in their mental health journey or if they believe their Spouse or Partner's support could be beneficial to the therapeutic process. Your comfort and preferences are important to us, and we respect your decision in this matter.
Legal Name of Spouse or Partner:
Preferred Name
Date of Birth (DOB):
MM
/
DD
/
YYYY
Phone Number
Email Address
How did you hear about Brave?
 *
Required
What is the Name of the individual who referred you? 
[ First Name, Last Name ]
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Brave LLC. Report Abuse
Google Forms