New Client Screening

Name of potential client

Client's date of birth

Email Address

Phone

Reason for seeking therapy?

How would you prefer to communicate

Text (fastest response)

Email

Phone Call

Method of payment

How did you hear about us?

Select an option

I understand that all sessions are via telehealth

I am not interested in telehealth. Please disregard this submission.

Select an option

I understand that all appointments will be between 8am-5pm.

Appointments between 8am- 5pm will not work for me. Please disregard or reach out with additional options.

Let's get to work!