Interested in Starting Therapy? Fill Out Our Pre-Therapy Questionnaire.

Randall Therapeutic Services

Pre-Therapy Questionnaire
Full Name*

First NameLast Name
Date of Birth*
MM/DD/YYY
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
What is the reason you are seeking therapy?*
What are your goals or what do you wish to achieve in therapy?*
Is there a specific therapist you would like to work with?*

Nikki Gudenschwager, LPCSarah James, LPC-ITCarli Reynolds, APSWNo Preference
Please help us understand the amount of sessions you are looking for. If you don't have a specific number of sessions in mind that is okay! Our therapists will help you determine your timeline based upon your therapy goals.*

1-56-1011-1516+I'm not sure
What is your availability like?*
For your therapy sessions, do you have a preference on location? Please select all that apply.*

HomeOfficeTelephoneOnline via video-conferencing
Thank you for taking the time to fill out this form. We look forward to meeting you!

-The Team at Randall Therapeutic Services
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