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.
4. Preferred Contact Method:*

Phone CallVoicemail (can leave a messsage)Email
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?*

Less than 1 month1-3 months3-6 monthsMore than 6 months
8. Have you previously received any form of counseling or therapy?*

YesNo
If yes, what type of therapy, and was it helpful?
9. What is your preferred type of therapy?*

Individual therapyGroup therapyChildren's TherapyUnsureOther
5. What is your preferred mode of therapy?*

In-personVirtual
6. Preferred language for therapy sessions:*

EnglishUrduPunjabiArabicOther
Insurance and Availability
7. Is your therapy covered under an insurance plan?*

YesNoNot sure
8. Are there any times or days of the week that work best for you? (Please select all that apply.)*

Weekday MorningsWeekday AfternoonsWeekday EveningsWeekends
14. How soon would you like to begin therapy?*

As soon as possibleWithin 1-2 months2-3 monthsFlexible
Do you have any questions for us?
Should be Empty:

Interest Form for Individual Therapy

Personal Information

Therapy Related Information

Insurance and Availability