Client Intake Form

Who will therapy be for?* This field is required.

My partner and me

Someone else

First and Last Name* This field is required.

Email* This field is required.Your information is private and will only be used to help connect you with care at our practice.

example@example.com

Phone* This field is required.

Please enter a valid phone number.

Date of birth* This field is required.

Date

Gender* This field is required.

Man (cisgender)

Woman (cisgender)

Agender

Gender fluid

Gender nonconforming

Non-Binary

Queer

Trans man

Trans woman

Two-spirit

Other

Prefer Not To Say

State* This field is required.

Which areas would you like support with?* This field is required.Select all that apply, we’ll help guide you from here.

Anxiety or feeling overwhelmed

Depression or low mood

Stress, burnout, or work/school challenges

Relationship concerns

Self-esteem or self-worth

Life transitions or feeling stuck

Panic attacks

Insomnia or sleep difficulties

Emotional regulation / intense emotions

Grief or loss

Obsessive Compulsive Disorder (OCD)

Attention-Deficit/Hyperactivity Disorder (ADHD)

Trauma or PTSD

Eating or body image concerns

Substance use

Stress related to physical health

Couples therapy

Something else

In your own words, what would you like support with?* This field is required.Feel free to share as much or as little as you’d like. This can help us connect you with a great fit.

Which services are you interested in?* This field is required.Not sure what’s best? Select any options you may be interested in, and we’ll help guide you.

Individual Therapy

Couples Therapy

Self-Compassion for Stress & Anxiety Group

DBT Skills Group

ADHD Skills Group

ADHD Assessment

Other

Have you ever participated in a higher level of mental health care or support program?* This field is required.

Yes - IOP

Yes - PHP

Yes - Hospitalization

I'm not sure

Prefer not to say

Are any of the following part of your current experience?* This field is required.Select all that apply - this helps us make sure we connect you with the right level of support. This screener is reviewed by a staff member during business hours [Mon-Fri, 9am-5pm]. It is not monitored in real-time. If you are in crisis right now, please call or text 988, call 911, or go to your nearest emergency room. Do not wait for a response from our office.

Self-harm or hurting yourself recently

A recent suicide attempt

Thoughts of suicide or not wanting to be alive

Alcohol or substance use that feels hard to manage right now

Periods of feeling unusually energized, needing very little sleep, or feeling unlike yourself

Hearing, seeing, or experiencing things that others may not

Anger, aggression, or urges to hurt someone

Current legal or court-related stress

None of these

Prefer not to say

How has day-to-day life been lately?* This field is required.Pick the one that most closely describes where you're at these days.

Things feel manageable overall

Some areas feel harder than usual

I’m feeling overwhelmed at times

I’m struggling to keep up with some responsibilities

I’m struggling to keep up with most responsibilities

Day-to-day functioning feels really hard right now

I’m having a hard time getting through basic daily tasks

How did you hear about us?* This field is required.If someone referred you, feel free to include their name.

Insurance & Therapy Coverage* This field is required.Will you be using insurance or self-pay for services?

Insurance DetailsIf you'd like an insurance courtesy check, you can enter your insurance information below or upload a photo of your insurance card on the next page. (Please include your member ID, full name, and date of birth)

Insurance Card UploadOptional: You can upload a photo of your insurance card instead of entering your information manually.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Is there a type of therapy you’re looking for?No worries if you’re not sure — many people aren’t, and we’re happy to help guide you.

Cognitive Behavioral Therapy (CBT)

Exposure and Response Prevention (ERP)

Acceptance and Commitment Therapy (ACT)

Self-Compassion–Focused Therapy

EMDR

Trauma-Informed Therapy

Internal Family Systems

Psychodynamic Therapy

I’m not sure / open to recommendations

Is there anything you'd like us to know to help find a good fit?For example: therapist preferences, scheduling or insurance questions, or anything else you'd like us to know.

If you are experiencing a medical emergency, call 911 or go to the nearest emergency room. If you are experiencing a mental health crisis, call or text 988 for immediate support.

By submitting this form, you consent to the secure review and processing of sensitive personal information, which may include protected health information (PHI), by members of our practice team to help connect you with appropriate care. Please do not include credit card or other payment information in this form.