WellMatched Therapist Intake Form

1
Terms and Conditions* This field is required.
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What is your legal first and last name?* This field is required.
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What is your email address?* This field is required.
example@example.com
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Where are you physically located?* This field is required.
Street Address
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City
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Canada
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Chile
China
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Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
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Greenland
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Guadeloupe
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Guyana
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Hong Kong
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Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
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Jamaica
Japan
Jersey
Jordan
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Kiribati
North Korea
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Laos
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Lesotho
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Libya
Liechtenstein
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Macedonia
Madagascar
Malawi
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Mexico
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Northern Mariana
Norway
Oman
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Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Select Your Time Zone* This field is required.
Eastern Time (ET)
Central Time (CT)
Mountain Time (MT)
Pacific Time (PT)
Alaska Time (AKT)
Hawaii-Aleutian Time (HAT)
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We'd like to get to know you! Please share your Psychology Today or practice website URL below.* This field is required.
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What type of credentials/degree do you hold?* This field is required.
Please Select
Please Select
PhD
PsyD
EdD
LMFT
LCSW
LPC
LMSW
LICSW
MSW
MFT
LPCC
LCPC
LMHC
NCC
Pre-licensed (e.g., Pre-licensed: associate-level, registered intern, postdoc)
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Do you hold any professional designations, board certifications, or advanced credentials (e.g., Board Certified in Clinical Psychology, Diplomate status, PMH-C, BCBA, etc.)? Please list them here.* This field is required.
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Are you authorized by an interstate compact that allows occupational licensing reciprocity among states (e.g., PSYPACT)?* This field is required.
YESNO
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List Your Licenses (Individual States, not compact)* This field is required.
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List Your Interstate Compact License Information* This field is required.
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NPI number* This field is required.
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Have you had any disciplinary actions from your state board?* This field is required.
YESNO
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Describe the disciplinary actions you had from your state board.
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Upload Proof of Liability Insurance* This field is required.
Drag and drop files here
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How many years have you been in clinical practice?* This field is required.
0-2
2-5
5-10
10+
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What is your typical response time when a new client reaches out?* This field is required.
Within 24 hours
1-3 business days
5-7 business days
1 week or longer
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When can you offer therapy sessions?* This field is required.Select all that apply
Mornings (8-12pm)
Afternoons (12-4pm)
Evenings (4-8pm)
Weekends
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Do you offer complimentary consultations?* This field is required.
YESNO
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How soon can you typically offer an intake?* This field is required.
Within 1 week
2-3 weeks
1 month+
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What session formats do you offer? (Select all that apply)* This field is required.
In-person
Telehealth (Video)
Phone
Hybrid
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Are you in network with any insurance plans?* This field is required.
YESNO
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Which insurance plans do you accept? (Select all that apply)
Blue Cross Blue Shield (e.g., Highmark, Anthem, Horizon BCBS)
Aetna
Cigna
UnitedHealthcare / Optum (e.g., UHC, Oscar Health)
Kaiser Permanente
Medicare
Medicaid
Employee Assistance Programs (EAPs)
TriCare (Military Insurance)
Other Private Insurance (list below)
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Other Private Insurance:
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Do you provide Superbills for out-of-network reimbursement?* This field is required.
YESNO
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What is your standard self-pay session fee?* This field is required.
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Intake session fee (if different from standard fee):
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Do you offer sliding scale?* This field is required.
YESNO
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Which age populations do you work with? (Select all that apply)* This field is required.
Children (under 9)
Preteens (9-12)
Teens (13-17)
Young adults (18-24)
Adults (25-64)
Older Adults / Seniors (65+)
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Please select any affirming approaches or clinical lenses you integrate into your practice.* This field is required.
Trauma-informed
Somatic-informed
Neurodivergent-affirming
Culturally responsive
Anti-racist
LGBTQIA+-affirming
Gender-affirming
Disability-affirming care
Body liberation / HAES-informed care
Faith-affirming
Relationship diversity-affirming (e.g., polyamory, non-monogamy)
None of the above
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Treatment Modalities* This field is required.Please select the therapeutic approaches you are trained in and currently use in your clinical work. We understand that therapists often draw from multiple modalities. Please only select those you use regularly and feel confident applying in your current practice.
Acceptance and Commitment Therapy (ACT)
Applied Behavior Analysis (ABA)
Applied Tension (BII Phobia)
Behavioral Activation (BA)
Biofeedback
Brainspotting
CBT for ARFID (CBT-AR)
CBT for Chronic Pain (CBT-CP)
CBT for Insomnia (CBT-I)
CBT for Substance Use (CBT-SUD)
CBT-Panic (Interoceptive + In-Vivo Exposure)
Child-Parent Psychotherapy (CPP)
Cognitive Behavioral Therapy (CBT)
Cognitive Processing Therapy (CPT)
Cognitive Rehabilitation / Remediation
Cognitive Stimulation Therapy (CST)
Compassion-Focused Therapy (CFT)
Comprehensive Behavioral Intervention for Tics (CBIT)
Co-Parenting Counseling
Dialectical Behavior Therapy (DBT)
Early Start Denver Model (ESDM)
Ecopsychology
Emotionally Focused Therapy (EFT)
Enhanced CBT for Eating Disorders (CBT-E)
Executive Function Coaching
Existential / Humanistic Therapy
Exposure and Response Prevention (ERP)
Eye Movement Desensitization and Reprocessing (EMDR)
Faith-Integrated Therapy
Family Systems / Structural Family Therapy
Family-Based Treatment (FBT)
Family-Based Treatment for ARFID (FBT-ARFID)
Functional Family Therapy (FFT)
Gottman Method
Graduated Exposure
Gut-Directed Hypnotherapy (GDH)
Habit Reversal Training (HRT)
Imagery Rehearsal Therapy (IRT)
Inference-Based CBT (I-CBT)
Integrative Behavioral Couples Therapy (IBCT)
Integrative Therapy
Internal Family Systems (IFS)
Interpersonal Psychotherapy (IPT)
Meaning-Centered Psychotherapy (MCP)
Mind-Body Therapy
Mindfulness-Based Cognitive Therapy (MBCT)
Mindfulness-Based Stress Reduction (MBSR)
Motivational Interviewing (MI)
Narrative Exposure Therapy (NET)
Narrative Therapy
Paced Activity Management
Parent Coaching / Behavioral Parenting Strategies
Parent-Child Interaction Therapy (PCIT)
Pediatric Behavioral Sleep Therapy
Pediatric CBT (CBT-Child)
Pivotal Response Training (PRT)
Play / Sandtray Therapy
Polyvagal / Nervous System-Informed Work
Problem-Solving Therapy (PST)
Process-Based CBT (PBT)
Prolonged Exposure (PE)
Prolonged Grief Treatment (PGT/PGDT)
Psychodynamic Therapy
Relational Psychotherapy
Schema Therapy
Sensorimotor Psychotherapy (SP)
Sex Therapy
Social Skills Training
Solution-Focused Brief Therapy (SFBT)
Somatic Experiencing (SE)
SPACE (Parent-Based Treatment)
Trauma-Focused CBT (TF-CBT)
Trauma-Informed Yoga / Movement
Unified Protocol (UP)
None of the above
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Have you completed formal training/certification or supervised delivery for any structured or trademarked protocols (e.g., manualized protocols)?* This field is required.
YESNO
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Which of the following clinical protocols/manualized interventions have you been formally trained or certified in?
Applied Behavior Analysis
Applied Tension (BII Phobia)
Brainspotting
CBT for ARFID (CBT-AR)
CBT for Chronic Pain (CBT-CP)
CBT for Insomnia (CBT-I)
CBT for Substance Use (CBT-SUD)
CBT-Panic (Interoceptive + In-Vivo Exposure)
Cognitive Processing Therapy (CPT)
Cognitive Rehabilitation / Remediation
Cognitive Stimulation Therapy (CST)
Comprehensive Behavioral Intervention for Tics (CBIT)
Early Start Denver Model
Emotionally Focused Therapy (EFT)
Dialectical Behavior Therapy
Enhanced CBT for Eating Disorders (CBT-E)
Exposure and Response Prevention (ERP)
Family-Based Treatment (FBT)
Family-Based Treatment for ARFID (FBT-ARFID)
Gottman Method
Graduated Exposure
Habit Reversal Training (HRT)
Imagery Rehearsal Therapy (IRT)
Inference-Based CBT (I-CBT)
Integrative Behavioral Couples Therapy (IBCT)
Internal Family Systems (IFS)
Meaning-Centered Psychotherapy (MCP)
Narrative Exposure Therapy (NET)
Parent-Child Interaction Therapy
Pediatric Behavioral Sleep Therapy
Pediatric CBT (CBT-Child)
Pivotal Response Training
Polyvagal / Nervous System-Informed Work
Prolonged Exposure (PE)
Schema Therapy
Sensorimotor Psychotherapy (SP)
Sex Therapy
Social Skills Training (manualized group formats)
Somatic Experiencing (SE)
SPACE (Parent-Based Treatment)
Trauma-Focused CBT (TF-CBT)
Trauma-Informed Yoga / Movement
Unified Protocol (UP)
None of the above
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For each protocol you selected to have been formally trained in, please provide verification for each (*Please note, you may need to scroll over to answer the 5th question):* This field is required.
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Treatment Specializations* This field is required.Please select no more than 3 areas where you feel most confident and experienced in your clinical work. These should reflect your core specializations—the types of client concerns, diagnoses, or populations you consistently treat, enjoy working with, and would want to be matched with more often.
Anxiety, Fear & Intrusive Thoughts
Career & Work Identity
Cognitive Functioning & Neuro‑Rehab
Cultural, Racial & LGBTQIA+ Identity
Eating, Body Image & Appearance
End-of-Life, Death & Grief
Identity, Change & Life Transitions
Impulsivity, Addiction & Risk
Intrapersonal Functioning
Mood & Emotional Regulation
Neurodivergence & Cognitive Differences
Parenting, Caregiving & Family Roles
Physical Health, Hormones & Sleep
Relational Pattern
Relationships, Attachment & Intimacy
Reproductive & Perinatal Mental Health
School & Academic Functioning
Self-Worth
Trauma & PTSD
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Anxiety, Fear & Intrusive Thoughts
Agoraphobia & Public Space Avoidance
Anxiety (General)
Body‑Focused Repetitive Behaviors (BFRBs)
Generalized Anxiety Disorder (GAD)
Health / Illness Anxiety
Intrusive Thoughts & Rumination
Obsessive‑Compulsive Disorder (OCD)
OCD / Rigid Thinking (Kids & Teens)
Panic Disorder & Panic Attacks
Religious OCD / Scrupulosity
Selective Mutism (Kids)
Separation Anxiety (Adults / Kids)
Social Anxiety (Kids & Teens)
Social Anxiety Disorder (Adults)
Specific Phobias
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Career & Work Identity
Burnout from High-Achievement Pressure (Work‑Specific)
Career Transitions & Uncertainty
Creative Blocks & Purpose‑Driven Work Stress
Entrepreneur Mental Health
High-Pressure Careers (e.g., Tech, Law, Medicine)
Workplace Identity & Values Conflict
Workplace Trauma or Toxic Environments
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Cognitive Functioning & Neuro‑Rehab
Brain Fog / Post‑Illness Cognitive Issues
Cognitive Rehab After Illness or Injury
Neurodegenerative Cognitive Decline
Post‑Concussive Syndrome
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Cultural, Racial & LGBTQIA+ Identity
Cultural / Racial Identity Stress
Cultural Identity & Code‑Switching Stress
First‑Gen & Immigrant Experience
Gender Identity & Transition Support
LGBTQIA+ Family/Peer Judgment & Acceptance
LGBTQIA+ Identity Exploration & Support
Systemic Oppression & Identity Stress
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Eating, Body Image & Appearance
Anorexia Nervosa
ARFID / Sensory‑Based Food Avoidance
Binge Eating Disorder (BED)
Body Dysmorphic Disorder
Body Image Concerns (no ED)
Bulimia Nervosa
Compensatory Behaviors (purging, over‑exercise)
Emotional or Stress Eating
Food Addiction
Orthorexia / Health‑Oriented Restriction
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End-of-Life, Death & Grief
Complicated / Prolonged Grief
End‑of‑Life Psychological Support
Grief & Bereavement Support
Non‑Death Grief & Living Losses
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Identity, Change & Life Transitions
Adjustment Disorder / Life Stress
Disability Identity & Accessibility Stressors
Existential Anxiety / Meaning Struggles
Faith Deconstruction & Transition
Identity Confusion / Exploration
Life Purpose / Values Work
Spirituality & Existential Exploration
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Impulsivity, Addiction & Risk
Alcohol / Substance Use
Compulsive Sexual Behavior / Porn Addiction
Compulsive Spending / Shopping Addiction
Dual Diagnosis (SUD + MH)
Gambling
Impulse Control Disorders
Lying, Stealing or Risky Behavior (Kids & Teens)
Risky / Impulsive Behaviors
Screen / Tech Overuse & Gaming Addiction
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Intrapersonal Functioning
Boundary Setting & Challenges
Fear of Failure
Indecisiveness / Overthinking
People‑Pleasing & Overfunctioning
Perfectionism
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Mood & Emotional Regulation
Bipolar & Mood Spectrum Disorders
Emotional Dysregulation (Kids & Teens)
Emotional Dysregulation / Affective Instability
Emotional Suppression / Avoidance
Irritability / Anger Regulation
Major Depressive Disorder
Oppositional / Aggressive Behavior (Kids)
Persistent Depression / Dysthymia
Self‑Harm & NSSI
Suicidal Ideation
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Neurodivergence & Cognitive Differences
ADHD
Autism Spectrum & Identity
Executive Functioning Challenges
Giftedness / Twice‑Exceptionality (2e)
Masking / Camouflaging Support (Neurodivergence)
Misophonia
Pathological Demand Avoidance
Procrastination / Initiation (ADHD)
Rejection Sensitivity (RSD)
Sensory Processing & Sensitivity Support
Supporting Neurodivergent Children
Tics or Involuntary Movements
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Parenting, Caregiving & Family Roles
Blended Family Support
Caregiver Stress & Burnout
Co‑Parenting / Parenting Conflict
General Child & Adolescent Behavior Concerns
Infant Feeding / Sleep Stress
NICU & Medically Complex Parenting
Parentification & Childhood Role Confusion
Parenting After Trauma
Parenting Stress / Burnout
Sibling Conflict or Aggression
Single Parenting Support
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Physical Health, Hormones & Sleep
Adjustment to Medical Devices / Physical Changes
Cancer Support & Survivorship
Chronic Illness
Chronic Pain
Hormonal Mood Changes
Insomnia & Sleep Difficulties
Medically Complex / Rare Diagnoses
New or Uncertain Medical Diagnosis Support
Nighttime Anxiety & Sleep Distress
Perimenopausal Mental Health
PMDD & Menstrual Mental Health
Post‑Viral Fatigue / Long COVID
Procedure‑Related Phobias & Healthcare Avoidance
Somatic Symptoms & Nervous System Dysregulation
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Relational Pattern
Difficulty Making or Keeping Friends (Adults)
Emotionally Unavailable / Invalidating Relationships
Narcissistic Abuse / Coercive Control
Relationship Conflict & Communication
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Relationships, Attachment & Intimacy
Attachment Wounds & Fear of Abandonment
Divorce / Breakup / Family Estrangement
Infidelity / Betrayal Recovery
Polyamory, Kink & Nontraditional Relationship Support
Trust & Intimacy Struggles
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Reproductive & Perinatal Mental Health
Abortion Decision & Post‑Abortion Support
Birth Trauma & Recovery
Fertility / Conception Stress
Gestational Carrier / Surrogacy Support
High‑Risk Pregnancy Support
Perinatal Mood Disorders (PPD, Anxiety, Rage)
Perinatal OCD
Pregnancy Loss (Miscarriage, Stillbirth, TFMR)
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School & Academic Functioning
Academic Stress
Burnout from High Achievement (Students)
Learning Differences & School‑Based Struggles
School Avoidance
School Communication Anxiety / Conflict
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Self-Worth
Bullying / Peer Exclusion / Social Rejection
Peer Pressure & Self‑Concept
Self‑Esteem / Self‑Worth
Shame & Self‑Criticism
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Trauma & PTSD
Caregiver / Helper Role Moral Injury
Childhood / Developmental Trauma
Complex Trauma (C‑PTSD)
Housing Instability / Financial Trauma
Intimate Partner Violence / Relationship Abuse
Medical Trauma & Healthcare Mistrust
Occupational Trauma / First Responder & Military Exposure
PTSD (Post‑Traumatic Stress Disorder)
Religious or Spiritual Trauma
Sexual Trauma & Boundary Violations
Somatic Trauma Responses (dissociation, freeze, etc.)
Trauma from Immigration / Displacement
Trauma Recovery for LGBTQIA+ & Marginalized Identities
Trauma Recovery for BIPOC & Oppressed Identities
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For each specialization you chose above, please provide verification:* This field is required.
56
Do you routinely track treatment outcomes using measurement-based care? (e.g., PHQ-9, GAD-7, Y-BOCS, PCL-5, OCI-R)* This field is required.
YESNO
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What measures do you commonly use?* This field is required.
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How would you describe your general communication tone in sessions?* This field is required.Select all that apply.
Clear, goal-focused communication; comfortable offering feedback or guidance
Supportive, validating, compassionate communication
Curious, probing, meaning-making conversation style
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How do you tend to show up relationally with clients?* This field is required.Select all that apply.
Grounded, soothing presence; emphasizes emotional safety
Shared decision-making and flexibility; balances guidance with curiosity
Accountability and growth-oriented challenge; comfortable naming stuck points
Uses humor, creativity, or metaphor to promote engagement
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Are you open to being matched with clients based on shared identity or lived experience?* This field is required.(This includes optional information like race, gender identity, neurodivergence, faith, or life roles that clients may be looking to connect around.)
YESNO
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What is your age range?This helps us better understand the life experiences and generational perspectives you bring to your work.
Under 25
25–34
35–44
45–54
55-64
65+
Prefer not to say
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What gender identity do you identify with?
Woman
Man
Non-binary / Genderqueer / Gender Fluid
Transgender Woman
Transgender Man
Agender
None / no preference
63
What sexual orientation(s) do you identify with?
Lesbian
Gay
Straight
Bisexual
Pansexual
Asexual
Queer
Questioning
Transgender
Nonbinary
Genderqueer
Prefer Not to Say
Other
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What racial or ethnic identities do you hold?
Black or African American
Hispanic or Latine
Asian or Asian American
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
Indigenous or Native
Multiracial
White
Prefer not to say
Other
65
Are there any cultural, ethnic, or ancestral identities you’d like us to be aware of?
Caribbean
South Asian
East Asian
Arab / MENA
Latine / Hispanic
African diaspora
Multicultural
Prefer not to say
No / N/A
Other
66
Do you identify as neurodivergent?Select all that apply
ADHD
Autism
Sensory Processing Differences
Learning Differences
I'm exploring this
Prefer not to say
No / N/A
Other
67
Do you identify as disabled or as someone living with a chronic illness, chronic pain, or other long-term health condition?Select all that apply
Physical Disability
Chronic Pain
Chronic Illness
Fatigue or Energy Limitations
Mental Health Disability
Invisible Disability
Prefer not to say
No / N/A
Other
68
Do you hold any religious, spiritual, or faith-based identities?
Agnostic / Questioning
Atheist / Secular
Buddhism
Christianity
Hinduism
Islam
Judaism
Pagan or Earth-Based Spirituality
Spiritual but not religious
Prefer not to say
No / N/A
Other
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Do any of these experiences apply to you?(Select all that apply.)
I am a first-generation American
I am a first-generation college student
I am an immigrant or refugee
I have lived experience navigating immigration systems
Prefer not to say
No / N/A
Other
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Do you have lived experience in any of the following roles?
Military service (veteran or active duty)
Military family member
Law enforcement
Firefighter / EMT / First responder
No / N/A
71
Have you provided care to someone in any of the following roles?
Parent or guardian
Caring for aging parents
Sandwich generation (caring for both children and elders)
Partner/spouse with a disability or illness
Child or sibling with medical or developmental needs
Professional caregiver
No / N/A
72
Final Attestation* This field is required.
Should be Empty: