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Patient Information
First and Last Name
Email
Phone number
Age
Type of Payment
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Who is your preferred therapist?
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What would you like to address in therapy?
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Anxiety
Trauma / PTSD
Bipolar disorder
Life transition
Relationship challenges
Self-esteem
Grief & loss
Dissociative identity disorder
Polyamory
Depression
Obsesive compulsive disorder
Borderline personality disorder
Job stress
Gender identity & related areas
Shame & self-criticism
Schizophrenia
Other
Have you attempted suicide in the past 6 months?
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Are you primarily seeking treatment for an eating disorder?
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Yes
No
Will any part of your therapy be connected to a legal case, court order, or other legal process? Are you also seeking documentation or a letter of support for medical procedures, FMLA, or an emotional support animal?
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Yes
No
Are you experienncing any active suicidality or thoughts of self-harm? Is so, please describe below. If not, please enter N/A.
Have you been hospitalized for a psychiatric condition in the past 6 months? Is so, please explain. If not, please enter N/A.
What else would you like to share?
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