Therapy Interest Form

Please select the option that applies to you:* This field is required.

I am an established patient and interested in Therapy

My Evolve provider referred me for therapy

I am an Evolve Team Member

Patient Name* This field is required.If you are the parent or guardian of a minor OR completing this form for someone else, please enter the patient's name

First Name

Last Name

Contact Email* This field is required.

example@example.com

Contact Phone Number* This field is required.

Please enter a valid phone number.

Which service are you interested in?* This field is required.Please select ONE option for your priority. Based on the initial assessment, we can explore additional options in the future.

Individual Therapy (Ages 18+)

Individual Child Therapy (Ages 5-11)

Individual Adolescent Therapy (Ages 12-17)

Couples Therapy (Ages 18+)

What are your main concerns for couples therapy?* This field is required.Select all that apply.

Boundaries

Communication Concerns

Communication Patterns

Individual Struggles Affecting the Couple

Infidelity/Affair Recovery

Intimacy and Connection

Life Transitions and Stressors

Parenting and Family Dynamics

Pre-Marital Counseling

Rebuilding Trust

Relationship Goal Setting

Separation Discernment/Divorce

Other

How would you like to be seen for therapy?* This field is required.Current wait times are 1 to 2 weeks for telehealth visits and 12-16 weeks for in-person, subject to therapist availability in your area. Based on the initial assessment, we may explore switching formats.

Telehealth

In Person

How will you be billed for therapy?* This field is required.See our cash pay fee schedule here.

InsurancePrivate Pay

Are you seeking therapy services to meet a legal requirement?* This field is required.See limitations in our scope of services with regards to legal cases here.

Family court

Custodial matters

Pending divorce

Guardianship / Conservatorship

Court mandated treatment

None of the above

Other

Will this be your first time receiving therapy for mental health concerns?* This field is required.

YESNO

Do you have a therapist/counselor that you are actively working with?* This field is required.It is important to note that having multiple therapists at one time can pose ethical concerns. If you are actively working with a therapist, we will assess if it is appropriate to establish an additional therapeutic relationship.

YESNO

Briefly share what type of therapy you are currently in and your reasoning for seeking out alternate options.* This field is required.Example: "I am currently in group therapy and would like to start seeing an individual counselor." or "I don't know if my current counselor is a good fit and I am exploring my options."

What are the primary concerns that you wish to address in therapy?* This field is required.Please pick your top 3 concerns to help us understand what is most important to you at this time.

Anger Management

Anxiety

Body Image Concerns

Compulsions

Depression

Eating Concerns

Impulsivity

Inattention

Interpersonal Difficulties

Intrusive Thoughts

Irritability

Loneliness

Low Self-Worth

Marital/Relational Concerns

Obsessions

Restlessness

Skin Picking/Hair Pulling

Sleep Disturbance

Social Anxiety

Substance/Alcohol Use

Trauma

Other (Free Text)

Other

What are your expectations for therapy?* This field is required.

I want someone with whom I can talk to and process things with.

I really like having a plan of action and set goals.

I like getting assigned readings and homework.

I'm not sure but am open to recommendations.

Other

Which of the following would you like your therapist to utilize and/or be familiar with?* This field is required.Please pick the top 3 qualities most important to you. This will allow us to pair you with the therapist we believe will be the best fit.

Acceptance and Commitment Therapy (ACT)

Body Positivity/Neutrality

Cognitive Behavioral Therapy (CBT)

Cognitive Processing Therapy (CPT)

Dialectical Behavioral Therapy (DBT)

Disability Advocacy

Eye Movement Desensitization and Reprocessing (EMDR)

Exposure and Response Prevention (ERP)

Familiar with Law Enforcement/Military

High-Conflict Couple

Humor in Session

Internal Family Systems (IFS)

LGBTQ+ Allied

Mindfulness

Multiculturally Sensitive

Neurodiversity Affirming

No Preferences

Person-Centered/Talk Therapy

Sensitive to Spiritual Practice/Religion

Trauma-Informed

Other

What times would you be able to commit to consistent therapy visits?* This field is required.Select up to 5 options.

Do you have a preferred therapist?We cannot guarantee you will be placed with your therapist of choice but our team will take this into account when selecting the best match for you. View our current therapy team here.

Counselor Name

Therapy Interest Form