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New Client Request Form
If you're here, maybe you're ready to work on yourself and begin a therapy journey! Filling out this form will help us see if our schedules and your goals are compatible. If they're not we are here to make sure you get supported!
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Name
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Your answer
Would you briefly describe what you're hoping to focus on in therapy. Or, what are you hoping to get support on?
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Your answer
What type of Counseling are you looking for?
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Individual Counseling
Couples Counseling
Ketamine Assisted Psychotherapy
Other:
Is the person needing services over the age of 18? Please note Activate Counseling Services only treats adults.
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Yes
No
Email Address
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Your answer
Phone Number
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Your answer
We are open Monday-Wednesday and Saturday. When would you ideally like to have your sessions scheduled?
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Your answer
What state do you currently live in?
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Your answer
Have you had prior therapy? If yes, when was the last time?
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Your answer
Do you currently have psychiatric care?
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Your answer
How did you learn about us?
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Psychology Today
Therapy Den
Google
Referral
Social Media
Other:
What are you ideally looking for?
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Telehealth Sessions
In Person Sessions
Hybrid Sessions (Both Telehealth and In Person)
Will you be paying with insurance or out of pocket?
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Insurance
Out of Pocket
If you are planning on using insurance, what current insurance do you have?
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Your answer
Are you willing to be put on a wait list if needed?
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Yes
No
Would like more information on this
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