What type of therapy are you seeking?
Individual
Couples
Family
One on One Intensives
Therapy Intake Form
IAM Enroot Therapy
What additional services are you seeking?
Psychoeducational groups
Support groups
Weekend Intensives
Therapeutic journal
Specific Treatment Intervention (CBT, somatic therapy, ketamine assisted psychotherapy, solutions focused therapy etc)
Personal Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Information
If you are interested in utilizing your OON benefits please complete the section below.
Insurance carrier
example@example.com
Member ID
Please upload Insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Member ID
*
-
Back
Next
Referral Information
How did you hear about us?
General Practitioner
Specialist
Family or friend
Social Media
Internet Search
Other
Referrer Name
First Name
Last Name
Referral Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Presenting issues
Reason for Counseling
Abuse
Adjustment
Anger
Anxiety
Depression
Displacement
Eating Disorders
Family
Financial Problems
Grief & Loss
Identity
Learning Difficulties
Loneliness
Obsessive Compulsive
Panic Attacks
Parenting
Post-Traumatic Stress
Relationship
Self-Esteem
Self-Harm
Sexual Issues
Sleeping
Smoking
Stress
Suicidal Thoughts
Trauma
Weight Concerns
Work Stress
Other
Please specify any previous counseling experiences
e.g. Mental Health Treatment Plan [MHTP], Employee Assistance Program [EAP], Private
Please provide additonal information regarding additonal services you are seeking.
Please specify any diagnoses
Please specify all medications
Please specify any other concerns. If seeking Couples Therapy please identify the name, email, D.OB, phone and address of your partner below.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Submit
Should be Empty: