Interest Form for Individual Therapy

Interest Form for Individual Therapy
We are excited to introduce a new service from Maternal Minds: individual therapy sessions conducted by registered therapists. Please complete the form below to join the waitlist.
Personal Information
1. Name:

First NameLast Name
2. Date of Birth:

MonthDayYear
Date
2. Email:
example@example.com
3. Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
4. Preferred Contact Method:
Therapy Related Information
6. What are the main concerns you'd like to address in therapy? (Examples: Anxiety, Depression, Trauma, Grief, Relationship Issues, Parenting, Identity Concerns, etc.)
7. How long have you been experiencing these concerns?
8. Have you previously received any form of counseling or therapy?
If yes, what type of therapy, and was it helpful?
9. What is your preferred type of therapy?

Other
5. What is your preferred mode of therapy?
6. Preferred language for therapy sessions:

Other
Insurance and Availability
7. Is your therapy covered under an insurance plan?
8. Are there any times or days of the week that work best for you? (Please select all that apply.)
14. How soon would you like to begin therapy?
Do you have any questions for us?
Should be Empty:

Personal Information