New Client Inquiry Form

Thank you for your response. ✨

Legal Name

How do you prefer to be addressed? (preferred pronouns, nickname, etc)

Phone number

Please indicate any contact restrictions (i.e. no texts, no voicemails, don’t call before 8am, etc)

What is your birthday?

How did you hear about us?

If you are completing this form on behalf of a potential client, please include your contact information below: Name, Email Address, Phone Number, and relationship to the potential client.

In what city and state do you currently live?

Please briefly describe the reason you are seeking help.

Have you been in therapy before? If so, can you describe the type of therapy you had and how it was helpful to you? (Please include any hospitalizations with reasons and dates)

What days and times do you prefer for appointments? (If you have scheduling restrictions please specify below.)

Are you looking for in-person or virtual appointments

Would you be comfortable being seen by an intern or prelicensed therapist for a reduced rate? (Interns are therapists in training who have completed most coursework and are closely supervised by multiple professors and fully licensed therapists, prelicensed therapists have completed a master’s degree and work under the close supervision of a fully licensed therapist)

Please include any additional questions or comments below.

Thank you for your response. ✨

Spread the Empowerment: