Intake Form
Welcome to Blue Couch Therapy—we’re here to help! Please fill out this form so we can better understand your needs. Once submitted, you’ll receive a call or text from our team within 24 hours. You may book a session or wait for a call back for a free 15-minute consultation.
Date
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Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
Name
Relationship
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently experiencing any of the following? (Select all that apply)
*
I feel anxious
I feel like I am stuck in life
My mood goes up and down
I have a hard time sleeping
Sometimes it's hard for me to focus or I focus for too long
My relationship is not going well
I don't want to do anything
I still think about things that happened in my childhood
I have a hard time getting started on tasks
I don't feel like I fit in
I want to be more social but don't know how
Work is overwhelming and I want to learn how to manage better
Other
What is your primary reason for seeking mental health support?
*
Do you plan to use insurance or self-pay services?
*
Insurance
Self-Pay
For insurance, please upload a clear picture of the FRONT of your insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
For insurance, please upload a clear picture of the BACK of your insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Which days are you available to meet? (Select all that apply)
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Which time block are you available to meet? (Select all that apply)
9am - 11am EDT
12pm - 2pm EDT
3pm - 5pm EDT
6pm - 8pm EDT
9pm - 11pm EDT
Once submitted, a member of our team will reach out to you within 24 hours.
Submit
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