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The Peaceful Place Intake Form
Please fill out our Intake Form so we can place you with the best therapist for your needs.
If you are looking to connect with The Peaceful Place about something other than therapy services, please email admin@thepeacefulplc.com.
* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
What brings you to therapy at this time?
*
Your answer
What services are you looking for?
*
Sex Therapy - Individual Only
Sex Therapy - Couples
EMDR
Brainspotting
Trauma Therapy
Couples Therapy
Ego Work/Self-Exploration
LGBTQIA+
Body Image/Disordered Eating
Family Therapy
Adolescents (ages 12-17)
Substance Use
Required
Which
clinician
are you looking to work with?
*
Shannon Young, LCSW
Ayrielle Williams, LCSW
Alexis Logan, LMSW
Shirin Mavaneh, Associate Counselor
Christopher Cartledge, LICSW
Raquelle Poindexter, Marriage and Family Clinical Intern
Other:
Are you aware that we are a Telehealth only practice? NOTE: Our clinicians only provide services to Virginia residents.
*
Yes
No
Are you looking to use Blue Cross Blue Shield (
Anthem, FEP, CareFirst PPO)
insurance?
*
Yes
No
I will be self-pay.
Have you experienced any suicidal thoughts in the past 6 months?
*
Yes, Actively (currently having suicidal thoughts with plan or intent)
Yes, Passively (thoughts of "what if I were not here" but no plan or intent to act)
No
Other:
Have you experienced any homicidal thoughts within the past 6 months?
*
Yes
No
Have you been hospitalized for any suicidal/homicidal attempts or psychotic symptoms (i.e. delusions, hallucinations) in the past year?
*
Yes - Suicidal
Yes - Homicidal
Yes - Psychotic Symptoms
No - I have not been hospitalized on a psychiatric unit in the past year.
Other:
Required
Do you experience any psychotic symptoms (hallucinations/delusions) or have you been diagnosed with any psychotic disorders previously?
*
I do not experience psychotic symptoms and have not been previously diagnosed with a psychotic disorder.
Yes, I do experience psychotic symptoms.
Yes, I have been diagnosed with a psychotic disorder previously.
Other:
Required
Please share anything that will help prepare for our meeting.
*
Your answer
Send me a copy of my responses.
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