New Client Inquiry
Hello! And welcome to The Journey Center for Healing Arts, PLLC. We are so glad you reached out for support and will be happy to help you find the best path for your unique healing needs.
We have several therapists in our office who specialize in a range of issues, and all of us have extended training in trauma-focused care. We use a variety of modalities to meet the needs of our clients, and appreciate the unique makeup of each client we work with. While we have a lot of training and specialties, not every modality is perfect for every client. There are no cookie-cutter programs here :-) If you have a need that we cannot meet, we will happily make a referral to a colleague who can likely give you the level of support you need.
The questions below are confidential, and will help us connect you with a clinician or referral source that will help you.
If you are completing this form for your child/dependent, and not yourself, please make sure to answer all questions below for that individual. Example: Their date of birth, not yours.
If you have questions, please give our office a call at 423.408.8041. We will be happy to talk with you about your needs.
What is your name and how you like to be addressed? (ex. Sybil Smith, she/her, preferred name Rebekah)
What is your birthdate?
In what state do you currently live? (For college students, name your current location, not state of residence)
If you are completing this form on behalf of the potential client, please include your contact information below: Name, Email Address, Phone Number, and relationship to the potential client.
How did you hear about us?
My physician recommended you
My friend or family member recommended you
Have you been in therapy (or hospitalizations) before? If so, can you describe the type of therapy you had and if it felt helpful to you?
If you have a preferred method of treatment, please describe it below. If you don't know, that's OK! We love introducing new clients to all of the modalities we use.
I'm seeking help for...
I feel out of sorts
I have anxiety or I worry a lot
I feel depressed, or sad
I need support for grief and loss
I have trauma or PTSD or get triggered a lot
I'm having a hard time in school
I have a hard time focusing or getting my work done
I have moods that change quickly and disrupt my relationships
Some of my relationships are hard to navigate
I feel insecure and want to be more confident
I'm looking for support while I transition
Being a parent (or new mom) is harder than I thought!
I'm interested in self-development work
My relationship needs help
My partner and I don't feel connected any more
My relationship is great, and want to enrich the connection we have
I am interested in...
Is there anything else you'd like for us to know?
Page 1 of 3
Never submit passwords through Google Forms.
This form was created inside of The Journey Center for Healing Arts, PLLC.