Potential New Client Interest Form

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We appreciate you providing this information. It's important to us to match you with the best therapist as quick as we can. We will get back to you via phone call once we determine if we are able to fit you in the schedule. Thank you so much, The Cognitive Refinery.

First & Last Name: *

Date of Birth: *

YYYY

Phone Number: *

Email: *

Health Insurance Carrier (or private pay): *

If we are not able to accept your insurance at this time, are you open to Private Pay? ($70-$130/hour)

Yes

Maybe

Clear selection

Availability (days and times you will be able to make appointments): *

Please select any relevant issues below: *

Depression

Problems with sleep

Loss of energy

Loss of appetite

Excessive eating

Anxiety

Loss of interest

Anger management

Legal issues

Substance abuse

Problematic sexual behaviors

Exhibit tics

Issues with hearing voices/visual hallucinations

Obsessions and compulsions

Academic failure

Abuse or trauma

Religious/Spirituality concerns

Self harming behaviors

Suicidal ideation/attempts

Relationship issues

Behavioral issues

Trouble focusing

Grief/Bereavement

Parenting concerns

Domestic violence

Required

Please elaborate on issues selected above (Ex: What is the cause of your anxiety? What behaviors are you exhibiting? What is the source of your trauma? etc.): *

Therapist Preferences (If you'd like to see a specific therapist, or have a gender preference, etc.):

How did you hear about us?

Submit

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