Erin E. Chavez, LMHC
Screening Questions
Sign in to Google to save your progress. Learn more
Name *
Preferred Name 
Preferred Pronouns
Email address  *
What health insurance do you have?  *
Date of Birth (If we set up an appointment, I need your date of birth to send you an invite to my patient portal.)  *
Do you feel like you can work with a feminist therapist? (You can read my website for more information about what it means to be a feminist therapist.) *
Do you identify as being a person in a marginalized group?
What are some of the reasons you are seeking therapy?
Do you prefer to have sessions in my office or by telehealth (Zoom or phone)? *
Do you have specific limitations on your schedule (such as needing evening appointments)? *
How often would you like to be seen (weekly, every other week, etc)? You may not have a clue and that is okay but if you have a strong preference, let me know.
How would you prefer I contact you after receiving this form? *
Phone Number (if you want a text or phone call)
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms