• Release it Counseling Intake Form

  • Welcome to Release It Counseling

    We’re honored that you’re taking this first step toward healing. Please complete the online intake form below thoroughly and accurately. This form is the first step in our onboarding process and helps us better understand how to support you.

    Important Navigation Tip:
    This is an embedded form. To move through the form—especially to reach the bottom—please scroll within the form itself, not the webpage.
    If completing this intake on behalf of someone else:
    The person who will be receiving services must personally sign all consents and documents in the client portal. We cannot proceed without their acknowledgment.

    We operate on grace and integrity, and we’re honored to walk beside you in this journey. Thank you for choosing Release It Counseling.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  •  -
  • Is your primary language English*
  • Current Symptoms*

  • Have you ever had feelings or thoughts that you didn't want to live?*
  • Do you currently feel that you don't want to live?*
  • Do you currently have or ever had a plan on how to commit suicide?*
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  • Please answer the below questions*
    Rows

  • Psychiatric History:

  • Have you been to therapy before?*
  • Please select if you've ever been diagnosed with any of the below*
  • Have you ever been placed in Psychiatric Hospitalization*
  • Have you been seen by a psychiatrist/NP/PA/MD in the last year (365 days)?

  • Past Psychiatric Medications

  • If you have ever taken any of the following medications?*
    Rows
  • Has anyone in your family been diagnosed with or treated for:*

  • Check if you have ever tried or used any of the following substances?*

  • Have you used any substances in the last 6 months?*
  • Are you presently using any Substances?*
  • Are you seeking Substance abuse treatment?
  • Do you presently smoke cigarettes?

  • Personal History

  • Have you experienced any trauma; domestic violence, sexual abuse, child abuse?*
  • Are you currently:

  • Legal

  • Are counseling services being requested or required as part of an active juvenile court, custody, child protective services, probation, or other legal matter?*
  • Is the person seeking services able to participate meaningfully in individual outpatient therapy, either independently or with limited support?*
  • Release It Counseling does not provide custody evaluations, forensic assessments, court recommendations, or routine court testimony. Are you seeking any of these services?*
  • Does the prospective client have developmental, intellectual, behavioral, or communication needs that may require specialized services or a higher level of care?*

  • Insurance Information

    If you do not have an image of your medical insurance, please list your Medical ID number In the Medical ID box. You can upload a blank image, but the Medical ID box must be filled if you do. If neither are completed your intake will be rejected.
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  • Please select which services you are interested in, you may select more than one. (Medication management is offered exclusively as part of integrated treatment and requires active participation in psychotherapy with a Release It Counseling therapist). COUPLES COUNSELING is NOT offered any longer.*
  • Does the prospective client have any developmental, intellectual, behavioral, or communication needs that could affect their ability to safely and meaningfully participate in telehealth services without ongoing agency assistance, excluding routine troubleshooting or technical issues originating on the agency’s end?*

  • Therapist Schedule & Availability

    Therapist Monday Tuesday Wednesday Thursday Friday
    Elektra 11a-2p 10a-3p 10-3p 10a-4p N/A
    Service Modality Virtual In person/Virtual In person/Virtual Virtual  
    Danesa N/A 12p-4p 12p-4p 12p-4p N/A
    Service Modality   In person/Virtual In person/Virtual  In person/Virtual  
    Dawn N/A N/A N/A N/A Appt only
    Service Modality        

    Virtual
  • Please select Your preferred therapist. (WHITNEY & CAMEO are no longer accepting any new clients)*

  • PLEASE READ BEFORE SUBMITTING

    Once you submit this form, please allow up to 5 business days for review. If you haven’t received a response after that time, you may follow up by emailing info@releaseit757.com. If your intake is approved, you will receive an email from SimplePractice with a link to register your client portal. You will have 72 hours from the time of that email to:

    1. Register the account
    2. Complete all onboarding consents
    3. Upload a valid credit/debit card on file (required for copays, deductibles, no show fees, etc)

    Failure to complete the portal registration or consents within the 72-hour window will result in deletion of the portal, and you will need to restart the intake process if still interested.

    We operate on grace and integrity, and we’re honored to walk beside you in this journey. Thank you for choosing Release It Counseling.

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