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Packages Form
HIPAA
Compliance
1
What brings you to therapy? (Select all that apply)
*
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Anxiety
Depression
Relationship challenges
Trauma or past experiences
Life transitions
Work or academic stress
Self-esteem issues
Anger management
Other
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2
How long have you been experiencing these concerns?
*
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Less than a month
1–3 months
3–6 months
More than 6 months
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3
What specific areas would you like to focus on in therapy? (Select all that apply)
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Managing emotions
Improving relationships
Building self-confidence
Stress management
Processing trauma
Developing coping strategies
Other
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4
Have you been to therapy before?
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Yes
No
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5
Full Name
*
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First Name
Last Name
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6
Date of Birth
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Date
Year
Month
Day
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7
Phone Number
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Please enter a valid phone number.
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8
Email
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example@example.com
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9
In which state are you currently residing?
*
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Please Select
Georgia
Louisiana
Texas
New York
Other
Please Select
Please Select
Georgia
Louisiana
Texas
New York
Other
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