Intake Form

Thank you for reaching out to our counseling practice. Please complete the questionnaire below so our Clinical Director can match you with the best therapist for your needs.

Name

First Name

Last Name

Phone

(###)

###

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What are you hoping to work on in counseling?

What time of day are you available for sessions?

Would you prefer in person or tele-therapy?

Are you planning to use health insurance? If so, which one do you have?