BIPOC Healing Collective Client Application
First name and First Initial of Last Name
*
Email
*
example@example.com
Phone Number (optional)
Pronouns
*
Languages spoken
*
Accessibility Needs (optional)
Session type preference
*
Telehealth
In-person
Either
Preferred therapist characteristics (e.g. Black, Asian, Non-Binary, faith-based, etc.)
*
Therapy approaches you're open to
*
Motivational Interviewing
CBT/DBT
Psychoeducation
Solution-Focused Brief Therapy
Other
Availability - when are you able to attend therapy/group sessions?
*
Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
What's bringing you in right now?
*
I understand
*
that funding is limited and this is not crisis care
I consent to be contacted for scheduling purposes
Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: