1. Let's get you checked in for your session

Who are you scheduled with today?

What type of session are you scheduled for today?

Other

First Name

Last Initial

Date of Birth

mm-dd-yyyy

Your Confidential Email

Confirmation Emailexample@example.com

Today's Date

Date

Thinking over the past week, how would you rate how well you're able to meet your basic personal physiological needs? (These include adequate food, clean water, clean air, restful sleep, and personal sexual fulfillment)

Which of these physiological needs seem most important to address today, if any?

Thinking over the past week, how would you rate your sense of safety and security? (These include areas like housing, finances, employment, mental & physical safety & health, and relative freedom from oppression/repression)

Which of these safety needs seem most important to address today, if any?

Thinking over the past week, how would you rate your sense of love and belonging? (This includes areas like friends, family, community relationships, and intimate relationships)

Which of these areas seem most important to address today, if any?

Thinking over the past week, how would you rate your sense of personal growth and accomplishments and how well they are acknowledged and recognized by others?

Which of these areas seem most important to address today, if any?

Over the past week, how would you rate your level of self-actualization? (This might mean achieving your full potential sense of calm, clarity, courage, creativity, connectedness, confidence, curiosity and compassion )

Which of these areas seem most important to address today, if any?

Over the past week, how would you rate your ability to feel some connection in the shared experience of being part of something bigger than yourself? Sometimes this may be the result of a spiritual awakening, finding your life's purpose, or other peak experience.

Your Psyche Score for this week is:

Are you now having, or have you ever had thoughts about ending your life or harming yourself?

E-Signature

Confirm E-Signature by typing your full name below:

E-Signature on file

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Click submit and you'll be sent to the waiting room and be sent a link via email. (Remember to check your spam folder)

In case of technical difficulty, your therapist will email you in the first 5 minutes of your session. Please check your spam folder.