ScheduleYourAppointment

as soon as tomorrow

Intake Form

Please fill out this form so that we may know a bit about your needs.

Full Name and Pronouns

Current State of Residence

Email Address

Phone Number

What type of therapy are you looking for?

Individual Therapy

Couples Therapy

Group Therapy

What are you hoping to work on in therapy?

Have you been previously diagnosed with a psychiatric disorder?

Yes

I'm not sure

If yes, please list and describe your current treatment for them (medication, previous therapy, etc.)

Are you currently experiencing suicidal thoughts?

Yes

Do you have a preference of clinician? (ex: LGBTQIA+, BIPOC, treatment specialty, etc.)

Thank you for submitting your response!

One of our clinicians will be reaching out to you shortly to schedule an appointment with you. Once scheduled, you will receive additional paperwork that must be completed prior to your first appointment.