Intake form

Help us serve you better

Name *

Email address *

What is your primary reason for seeking therapy?

Please select at least one option.

Anxiety

Depression

Stress Management

Relationship Issues

Personal Growth

Trauma

Self-Esteem

Life Transitions

Have you previously participated in therapy or counseling?

What specific goals do you hope to achieve through therapy?

How did you hear about our services?

Do you have any medical conditions or take any medications that may affect your therapy?

What are your preferred days and times for sessions?

Additional questions or comments

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Michelle, M.S.