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Zepp Wellness Therapy Intake
Thank you for your interest in our 3-month Intensive Mental Health Coaching service. Please be informed that this is not talk therapy– Raquel uses Eye Movement Desensitization and Reprocessing (EMDR) & Angie uses a personalized intensive therapy structure.
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Email
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Your email
Name
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Your answer
Pronouns
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Your answer
Birthdate
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MM
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DD
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YYYY
Phone number
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Your answer
Race
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Please Note: We only offer therapy services to Black, Indigenous, people of color.
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In what state do you live?
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Please note: Raquel sees clients, virtually, anywhere in the world. If you live outside of the United States, please note which country.
Your answer
Which provider would you prefer to see?
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Licensed Therapist
Peer Support Coach
Are you a SWer?
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Yes
No
Do you have consistent access to a private space, a device (ex. cell phone, laptop, etc.) and wi-fi in order to receive services?
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Yes
No
Have you previously received any type of mental health services?
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Yes
No
If yes, please briefly describe what kind of service(s) and your overall experience.
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Have you ever been hospitalized due to mental health concerns?
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Yes
No
Other:
If yes, please briefly explain.
Your answer
Have you ever been diagnosed with a psychotic disorder?
Yes
No
Maybe
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What would you like to accomplish or see change as a result of therapy?
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Your answer
Send me a copy of my responses.
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