Concierge Connection Questionnaire
Help us understand your therapy needs so we can match you with the right therapist. Your responses are securely handled and protected.
booking_id
Name
*
Email
*
*
I will not include specific diagnoses, medication names, provider names, or other confidential medical details in my responses.
*
I consent to having my responses used to guide my concierge matching process.
What brings you to therapy?
Anxiety or worry
Depression or low mood
Relationship issues
Family conflict
Grief or loss
Trauma or PTSD
Stress or burnout
Self-esteem concerns
Life transitions
Identity exploration
Parenting challenges
Work or career stress
Addiction or substance use
Eating or body image
Sleep difficulties
Anger management
Other concerns not listed above
0/500
What are your therapy goals?
Reduce anxiety or stress
Improve mood and emotional well-being
Build healthier relationships
Process pas trauma
Develop coping skills
Increase self-confidence
Navigate a major life change
Improve communication skills
Understand myself better
Manage specific symptoms
Support for parenting
Career or work-life balance
Other goals not listed above
0/500
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred session format
In-Person Only
Telehealth Only
Hybrid (Both)
No Preference
Preferred communication style
warm-supportive
direct-challenging
structured-practical
exploratory-reflective
mixed
Therapist preferrences (select any that apply)
No preference on demographics
Prefer a female therapist
Prefer a male therapist
Prefer a non-binary therapist
Prefer an LGBTQIA+ affirming therapist
Prefer a therapist of similar cultural background
Prefer a faith-based/spiritually-informed approach
Prefer a secular approach
Have you been to therapy before?
Yes, I have previous experience
No, this will be my first time
What worked or didn't work in your previous therapy experience?
0/500
What's most important in choosing a therapist?
Expertise in my specific concerns
Communication style match
Availability and scheduling flexibility
Location or telehealth options
Cost and insurance acceptance
Therapist demographics/identity
Specific therapeutic approach
Experience with my age group
Anything else youd like us to know?
0/1000
Make My Curated Connection
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