Therapy Interest Form
Please note that this form shall not be interpreted as entering you into a therapeutic relationship with Balanced Mind Therapy. This is an initial form to gather your basic information in order to determine if Balanced Mind Therapy is the best fit for your needs and goals.
IF YOU ARE FEELING SUICIDAL OR ARE HAVING ANY THOUGHTS OF HURTING YOURSELF, OR COMMITTING SUICIDE, DO NOT SEND A MESSAGE ON THIS FORM. PLEASE IMMEDIATELY CALL 911, GET YOURSELF TO THE NEAREST EMERGENCY ROOM, OR CALL THE NATIONAL SUICIDE PREVENTION LIFELINE AT 1-800-273-8255.
Legal Name
*
First Name
Last Name
Preferred Name
Pronouns
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Age (18+)
*
18-24
25-34
35-44
45-54
55-64
65 or older
Gender
Male
Female
Non-binary
Prefer not to say
Therapy Preferences:
Preferred Time for Sessions (Monday-Friday Virtual Sessions)
Morning
Afternoon
Evening
Type of therapy you are looking for
*
Individual therapy
Couple's therapy
Assessment for Infertility Treatment
Other
Topics of Interest (Check all that apply)
*
Anxiety
Depression
Stress Management
Relationship Issues
Grief and Loss
Self-Esteem
Trauma Recovery
Anger Management
Life Transitions
Sexual/Intimacy Challenges
Pregnancy or Infertility
Family Issues
Other
Goals and Expectations:
What brings you to therapy at this time? What are your general goals for participating in therapy? Please be specific but only share what you are comfortable sharing at this time.
*
Is there anything specific you would like me to know about your preferences or needs in a therapy setting? (E.g. you prefer a more gentle or direct approach, you have found benefit from a certain type of therapy in the past, etc)
*
How do you prefer to be contacted?
Phone
Email
Text Message
Schedule your 15-minute call
Submit
Should be Empty: