Client Intake Form

1
Are currently seeking therapy in the state of Illinois?* This field is required.
YESNO
2
Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
What is your age?* This field is required.To better personalize your service
6
What state do you reside in?* This field is required.
Illinois
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
7
What do you do for work?* This field is required.To help your client advisor provide tailored recommendations
8
How did you hear about Virsentio?* This field is required.Google, Social Media, Friend, Referral, etc.
9
What has made you decide to reach out for support at this particular time?* This field is required.
A specific life event or recent challenge
A growing awareness that I need to address ongoing feelings or difficulties
A recommendation from someone I trust
A desire to proactively invest in my mental and emotional well-being
I've been considering it for a while, and now feels like the right time
I don't see my reason listed or I'd prefer not to say
10
Have you ever sought out therapy or a mental health provider before?* This field is required.
Yes, I tried but never found a good fit
Yes, I've been to therapy and had a positive experience
Yes, I’ve been to therapy, but it didn’t meet my expectations
I've wanted to, but I'm unsure of where to start
No, this is the first time I've considered therapy
11
How do you view investing in your mental health and personal development?* This field is required.Select all that apply
I prefer low-cost or insurance-covered options only
I'm willing to pay out-of-pocket for the right fit, around $500 to $1,500
I see it as a critical investment and budget $1,500 to $3,000 for comprehensive matching and ongoing support
I prioritize premium service and results regardless of investment level
Should be Empty: