Client Intake Form

  • Let's find the best therapist for you

    Having a therapist you feel connected to is key. We'll ask you some questions to pair you with a licensed therapist who fits your therapy needs and preferences.

  • First, please tell us a little about yourself.

    This information will be kept confidential and helps us ensure we're able to provide you with care.
  • What can we help you with today? (select all that apply)*

  • You're in the right place.

    We're glad you're here. Our providers can diagnose what's going on and get you on the right treatment, so you can get back to being you.

  • Over the past 2 weeks, how often have you experienced the following?

    1/9
  • Little interest or pleasure in doing things.*

  • Over the past 2 weeks, how often have you experienced the following?

    2/9
  • Feeling down, depressed, or hopeless.*

  • Over the past 2 weeks, how often have you experienced the following?

    3/9
  • Trouble falling or staying asleep, or sleeping too much.*

  • Over the past 2 weeks, how often have you experienced the following?

    4/9
  • Feeling tired or having little energy.*

  • Over the past 2 weeks, how often have you experienced the following?

    5/9
  • Poor appetite or overeating.*

  • Over the past 2 weeks, how often have you experienced the following?

    6/9
  • Feeling bad about yourself - or that you are a failure or have let yourself or your family down.*

  • Over the past 2 weeks, how often have you experienced the following?

    7/9
  • Trouble concentrating on things, such as reading the news or watching television.*

  • Over the past 2 weeks, how often have you experienced the following?

    8/9
  • Moving or speaking slowly that other people have noticed. Or the opposite - being so restless or fidgety that you have been moving around a lot more than usual.*

  • Over the past 2 weeks, how often have you experienced the following?

    9/9
  • Thought that you would be better off dead, or of hurting yourself in some way.*

  • You indicated that you have had some thoughts about hurting yourself or that you'd be better off dead.

  • Would you describe these thoughts recently as:*

  • Unfortunately, we can't accept you at this time.

    Treating certain complex conditions requires closer interaction with a clinical provider than we can provide right now. Please visit/contact your referring provider (doctor, therapist, counselor) to discuss other clinical treatments. If you’re planning to hurt yourself, it’s important for you to get help right away. Your health is very important to us. If you are in distress or thinking about hurting yourself, please seek help using these crisis resources at any time.

  • Emergency Resources

    Suicide and Crisis Lifeline - 988 | Emergency Services - 911
  • How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

  • Over the past 2 weeks, how often have you been bothered by the following problems?

    1/7
  • Feeling nervous, anxious, or on edge.*

  • Over the past 2 weeks, how often have you been bothered by the following problems?

    2/7
  • Not being able to stop or control worrying.*

  • Over the past 2 weeks, how often have you been bothered by the following problems?

    3/7
  • Worrying too much about different things.*

  • Over the past 2 weeks, how often have you been bothered by the following problems?

    4/7
  • Trouble relaxing.*

  • Over the past 2 weeks, how often have you been bothered by the following problems?

    5/7
  • Being so restless that it is hard to sit still.*

  • Over the past 2 weeks, how often have you been bothered by the following problems?

    6/7
  • Becoming easily annoyed or irritable.*

  • Over the past 2 weeks, how often have you been bothered by the following problems?

    7/7
  • Feeling afraid as if something awful might happen.*
  • Have you tried anxiety or depression treatment before?*
  • What type of treatment have you tried (select all that apply):*
  • Have you ever attempted suicide before?*
  • When did your last suicide attempt occur?*
  • Have you ever been told by a doctor that you have schizophrenia or psychosis?*
  • Do you have health insurance?*

  • Your insurance may cover all or some of your care

    Let’s check your coverage to understand your options.

  • Name of Insurance Card

  • Insurance Company (select all that apply)*

  • We can provide you with the personal care you need. Now let’s setup your account.

    After, we’ll collect additional clinical information that will help your provider deliver great care. Our Telehealth Consent and Notice of Privacy Practices provide important information about the service we provide. By proceeding, you consent to them, and agree to adhere to our Members Rights and Responsibilities terms.
  • Format: (000) 000-0000.
  • Select your birthday*
     - -
  • Should be Empty: