New Client Request for Services

Name of Person Completing Form *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

What is the Reason for Seeking Services? *

Anxiety

Depression

Mindfulness

Self Esteem

Difficulty Adjusting

Coping with "-ism" Concerns

Trauma

Parenting Concerns

Life Transitions

Anti-Racism/Ally Work

Substance Use Concerns

Other: Please Describe

How would you prefer to attend sessions? *

Virtual

In person

Either works for me

Have you had therapy before?

Yes

No

Are you currently involved in a custody case, divorce or mandated by court to attend therapy? *

Yes

No

Are you currently suicidal? *

Yes

No

Have you ever attempted suicide? *

Never

Yes, in the last 6 months.

Yes, 6 months to 1 year ago.

Yes, longer than 1 year ago.

Payment Method *

Self Pay

Commercial Insurance (Please check with your insurance company that the requested provider is in network)

State Insurance (Please check with your insurance company that the requested provider is in network)

HSA/FSA Card

EAP Services

Preferred method of contact regarding your form: *

I am okay with emailing about services.