Pre-Therapy Questionnaire
Interested in therapy or our service array programming? Please fill out the form below!
Full Name (Individual who will receive the service)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Who will be the payee for the service? (please list name and phone number)
*
What is the reason you are seeking services?
*
What are your goals or what do you wish to achieve in Therapy?
Is there a specific Therapist you would like to work with?
Please help us understand the amount of sessions you are looking for. If you don't have a specific number of sessions in mind that is okay! Our therapists will help you determine your timeline based upon your therapy goals
What is your availability like?
For your therapy sessions, do you have a preference on location? Please select all that apply.
Home
Office
School
Community
Telehealth Only
Submit
Should be Empty: