Intake Form

1
Who is this appointment for?* This field is required.You can request this appointment for yourself, on behalf of someone else, or for both you and your partner. Please choose below.
Me
My child/children
My family
My partner and me
2
Your Name (If you are a parent, put your name here) * This field is required.
First Name
Last Name
3
Client's Name if under 18
First Name
Last Name
4
Your Email* This field is required.
example@example.com
5
Your Phone Number* This field is required.
Please enter a valid phone number.
6
Your Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Insurance* This field is required.We are only in network with Blue Cross Blue Shield. We provide out of pocket services to clients who have other insurance plans. Please look at our out of pocket costs on our website. We will provide private pay clients a superbill so they can seek reimbursement from their insurance.
Blue Cross Blue Shield (BCBS)
Other
Open to working with a clinician in training at a reduced rate of $30-$70 per session (will provide superbly for insurance reimbursement)
8
Date of Birth of the Client* This field is required.This is the date of birth of the person you are seeking care for.
Date
Year
Month
Day
9
What services is the potential client interested in?* This field is required.
Play Therapy
Child/Adolescent Counseling
Individual Counseling for Myself
Family Therapy
Couples Counseling
Parent Coaching
Psychological Evaluation/Testing
Individual Therapy for Parents
Individual Therapy for Grandparents
Executive Function Coaching
Biofeedback Training
Safe and Sound Protocol
DBT Skills Group for Tweens
High School DBT Skills Group
Play-Based DBT Group for Kids
RO-DBT Group
Undoing Perfectionism Group for Teens
10
What are the main concerns?* This field is required.
ADHD
Anxiety and OCD
Depression
Family and Marital Conflict
Impulse Control Issues
Trauma and PTSD
Parenting
Pregnancy, Prenatal, Postpartum
Women's Issues
Self-Esteem
Learning and School Challenges
Spirituality
Peer Relations
LGTBQ+
Aggression and Defiance
Autism
Sensory Processing Challenges
Adoption
Divorce
Grief and Loss
Life Transitions
Addiction
Self Harm and Suicidal Ideation
Sleep Issues
Eating Issues
Co-Parenting Challenges
Acculturation/Immigration
Other
11
Do you prefer virtual or in-person care?* This field is required.
Virtual
In-Person
I am flexible
12
Would you be open to before school hours or virtual appointments if it meant you would receive care sooner?* This field is required.
YESNO
13
What is the potential client's schedule availability?* This field is required.Please indicate all possibilities. The wait time is longer for evening hours.
I am flexible, first available.
Monday Morning (9 am - 12 pm)
Monday Afternoon (12 pm - 3 pm)
Monday Evening (3 pm - 8 pm)
Tuesday Morning (9 am - 12 pm)
Tuesday Afternoon (12 pm - 3 pm)
Tuesday Evening (3 pm - 8 pm)
Wednesday Morning (9 am - 12 pm)
Wednesday Afternoon (12 pm - 3 pm)
Wednesday Evening (3 pm - 8 pm)
Thursday Morning (9 am - 12 pm)
Thursday Afternoon (12 pm - 3 pm)
Thursday Evening (3 pm - 8 pm)
Friday Morning (9 am - 12 pm)
Friday Afternoon (12 pm - 3 pm)
Friday Evening (3 pm - 6 pm)
Saturday Morning (9 am - 12 pm)
Saturday Afternoon (12 pm - 3 pm)
14
What are the goals/concerns to work on in counseling?* This field is required.Please also note here if you have a strong preference for a specific counselor and would like to be considered only for their waitlist. This could effect wait time.
Huge
Large
Normal
Small
Ok
Ok
15
How did you hear about us?* This field is required.
Should be Empty: