Safety Check (Required)
Yes/No
Are you currently in crisis or feeling unsafe?
Are you having thoughts of harming yourself or someone else?
Are you seeking therapy following a recent psychiatric hospitalization or ER Visit?
Reason for Therapy
What brings you to therapy right now?
How long has this been going on?
Services Requested
Types of Therapy:
Session format:
Therapist preferences:
Fit Screening:
Have you been in therapy before?
Are you currently seeing another therapist?
Are you currently taking psychiatric medication?
Have you ever been diagnosed with a mental health condition?
Check any that apply:
Logistics
Payment Method:
Insurance (please note, we require insurance verification before scheduling the first session)
Self-pay
EAP (Employee Assistance Program)
Can you attend sessions consistenly (weekly/bi-weekly)?
Scheduling limitations (optional)
Final Notes
Anything else you'd like us to know? (optional)
How soon would you like to start?
