If you have had therapy before please provide details
Your answer
Have you ever been hospitalized for mental health? *
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Yes
No
If you have ever been hospitalized for mental health please provide details?
Your answer
Please check any that you are currently experiencing or have experienced in the last 30 days *
Any current mental health medications? *
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Yes
No
Do you have a history of trauma *
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Yes
No
What is your relationship status
Clear selection
Briefly describe the reasons for seeking therapy at this time. *
Your answer
Do you have a gender preference for your therapist? State yes or no. If yes please identify.
Your answer
Do you have health insurance? *
If you have health insurance please provide the name of the company, plan name, ID number, group number and the provider number from the back of the card.
Your answer
What is your address? *
Your answer
Availability or day/time of preferred appointment? Please provide as many options as possible *