Contact Name

Contact Phone Number

Contact Email Address

Type of Counseling Type of Counseling Individual Couples Family

Therapist Gender Therapist Gender No Preference Male Female

CLIENT'S Age Range: CLIENT'S Age Range: 0-5 years 6-11 years 12-14 years 15-18 years 19-25 years 26-35 years 36-49 years 50-65 years 65+

Are you looking to use insurance benefits to cover the cost of therapy? Are you looking to use insurance benefits to cover the cost of therapy? Yes, using insurance is a must Maybe/it depends I don't have or don't want/need to use my insurance

Please list your insurance below:

Describe why you are seeking therapy (or use checkboxes below):

Check all that apply: Check all that apply: Addiction Anger Anxiety Career-Related Issues Chronic Illness/Pain Depression Eating/Food Issues Grief/Loss

Check all that apply: Check all that apply: Identity Mental Health Diagnosis Relationship Issues Self-Esteem Self-Harm Spiritual Issues Trauma

Addiction - please specify: Addiction - please specify: Gambling Internet/Gaming Porn Sex Shopping/Spending Substance(s)

Identity - please specify Identity - please specify Gender Identity Racial Identity Sexual Identity/Orientation

Mental Health Diagnosis - please specify:

Relationship Issues - please specify: Relationship Issues - please specify: Co-Dependency Domestic Abuse Family Relationship/Conflict Marital Parent-Child Peer/Social Pre-Marital Separation/Divorce Sex Therapy