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.

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.*

Nearly every dayMore than half of daysSeveral daysNot at all

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

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

Nearly every dayMore than half of daysSeveral daysNot at all

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

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

Nearly every dayMore than half of daysSeveral daysNot at all

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

4/9
Feeling tired or having little energy.*

Nearly every dayMore than half of daysSeveral daysNot at all

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

5/9
Poor appetite or overeating.*

Nearly every dayMore than half of daysSeveral daysNot at all

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.*

Nearly every dayMore than half of daysSeveral daysNot at all

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.*

Nearly every dayMore than half of daysSeveral daysNot at all

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.*

Nearly every dayMore than half of daysSeveral daysNot at all

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.*

Nearly every dayMore than half of daysSeveral daysNot at all

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:*

A vague or general thought or feelingSomething I have made specific plans for

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?*

Extremely DifficultVery DifficultSomewhat DifficultNot Difficult At All

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

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

Nearly every dayMore than half of daysSeveral daysNot at all

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.*

Nearly every dayMore than half of daysSeveral daysNot at all

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

3/7
Worrying too much about different things.*

Nearly every dayMore than half of daysSeveral daysNot at all

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

4/7
Trouble relaxing.*

Nearly every dayMore than half of daysSeveral daysNot at all

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.*

Nearly every dayMore than half of daysSeveral daysNot at all

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

6/7
Becoming easily annoyed or irritable.*

Nearly every dayMore than half of daysSeveral daysNot at all

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.*

Nearly every dayMore than half of daysSeveral daysNot at all

Have you tried anxiety or depression treatment before?*

YesNo

What type of treatment have you tried (select all that apply):*

Antidepressants (e.g. lexapro, wellbutrin)Seeing an in-person therapistSeeing an online therapistOther prescriptions (e.g. xanax, ambien)None of the aboveOther

Have you ever attempted suicide before?*

YesNo

When did your last suicide attempt occur?*

Within the last 12 months1-5 years ago6-10 years agoMore than 10 years ago

Have you ever been told by a doctor that you have schizophrenia or psychosis?*

YesNo

Do you have health insurance?*

YesNo

Your insurance may cover all or some of your care

Let’s check your coverage to understand your options.
Name of Insurance Card
First Name*
Last Name*
Insurance Company (select all that apply)*

AetnaCignaBlue Cross Blue ShieldUnited HealthcareOther
Member ID*
Group ID*

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.
Please enter your best email to get access to the patient portal*
example@example.com
Please enter your best phone number so you can schedule your appointment*
Please enter a valid phone number.
Select your birthday*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
utm_campaign
utm_source
utm_term
utm_medium
utm_content
gclid
_gcl_au
fbclid
msclkid
first_utm_campaign
first_utm_source
first_utm_term
first_utm_medium
first_utm_content
ad_id
adset_id
ad_name
adset_name
utm_id
brand
browser
model
first_utm_url
first_utm_id
osversion
browserversion
city
country
engine
engineversion
isp
mobile
adgroupid
keyword
placement
first_ref
handl_landing_page
landing_page_base
ip
ref
domain
ref_domain
url
handl_url_base
organic_source
organic_source_str
gaclid
user_agent
first_domain
handl_id
stape
uid
_dcid
fpid
fpau
utm_url
translation_language
first_ref_domain
region
fpgclaw
fpgclgb
wbraid
_fbp
_fbc
_ttp
ttclid
os
trafficsourcename
tsource_id
obclid
pageviewCount
tabcid
phq9
gad7
srisk
Communication Confirmation*

I agree to receive mobile alerts related to my services with the practice. Message and data rates may apply. Frequency varies. Text STOP to cancel.
Should be Empty:

Let's find the best therapist for you

First, please tell us a little about yourself.

You're in the right place.

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

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

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

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

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

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

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

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

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

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

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

Emergency Resources

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

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

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

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

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

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

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

Your insurance may cover all or some of your care

Name of Insurance Card

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