New Client Form

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New Client Form

Welcome! We are so glad that you have chosen The Therapy Office for your mental health help! This form will help us get to know you better so you can be matched with the best therapist for you.

Email *

Client's First and last name *

Your name (If you're submitting a form on behalf of a client) *

Client Phone Number *

Client Date of Birth *

YYYY

Client Gender *

Street Address *

City, State and Zip Code *

Are you requesting a certain therapist? If so, check the box for the therapist you would like to see!

Becca Ferguson, LPC (In person sessions available)

Robert Stubbs, LPC (In person sessions available)

Help me choose the right fit!

Is the Client a minor? *

Yes

What time preference do you have for your appointments? *

Mornings (9:00am-11:00am)

Afternoon (11:00am-3:00pm)

Evening (3:00pm-5:00pm)

Other:

Required

What day preference do you have for your appointments? *

Monday

Tuesday

Wednesday

Thursday

Friday

Required

How soon are you needing to be seen? *

What services are you requesting? *

Individual Therapy

EMDR (Eye Movement Desensitization Reprocessing)

Group Therapy

Accelerated Resolution Therapy, ART (Becca Ferguson, LPC)

Other:

Required

Describe the reasons you are seeking help or services? *

In the past have you had suicidal thoughts or attempts? *

Yes

Are you currently having suicidal thoughts? *

Yes

Are you currently taking psychiatric medications? (If yes, please list your medications below). *

Have you had mental health treatment in the past? Where and when? *

Will you be using insurance? (If yes, please select the insurance you will be using)

*Please note: Insurance does not cover the cost of ART Intensives

Blue Cross Blue Shield

Anthem

Cigna

Aetna

Qualchoice

Ambetter

How did you hear about us? (Please list Name/Place so we can thank them!) *

Google

Facebook

Instagram

Another therapist

Other:

Required

Do you consent to text messages so we can reach out to you about your form? (Sometimes our email will go to spam boxes) *

Yes

Other:

Would you like to be added to our Self Care Sunday E-Mail List?

Yes

Clear selection

Is there anything else you would like The Therapy Office to know? *

Thank you!

The Therapy Office is so excited to have you as a potential client! Our admin team or therapist will reach out to you via email or phone in the next 48 business hours. Please note that our emails sometimes go to spam boxes. If you don't hear anything from us, please check your spam!

Thanks,

Becca Ferguson, LPC

Owner of The Therapy Office

Send me a copy of my responses.

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