Name *

First Name

Last Name

Pronouns

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He/him/his

She/her/hers

They/them/theirs

Unsure

Phone

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Do we have permission to leave a voice message? *

Yes

No

Are you a new client? *

Yes

No

Mode of therapy preferred *

In-person

Telehealth

No Preference

Please check which issues/concerns you would like to address *

Select all that apply

ADHD/Attention

Anger/Aggression

Anxiety/Panic

Body Image

Depression

Disordered Eating

Family Stressors

Grief/Loss

Intimate Partner Violence/Domestic Violence

Men's Issues

Mood Disorder

Personality Disorder

Racial Justice/Violence

Relationships

Stress

Substance Use

Trauma

Women's Issues

LGBTQ+ Issues

Other (please describe in comment section)

Preferences you would like considered in matching you with a provider *

A provider who_____. (Select all that apply)

Identifies as female

Identifies as male

Identifies as Black

Identifies as POC

Identifies as LGBTQ+

Identifies as LGBTQ+ affirming

Identifies as Hispanic or is Spanish-speaking

Has day-time availability

Has evening availability

Has weekend availability

I have no specific preferences/open to working with any provider

I was specifically referred to (please include in comments section)