Intake and Consent Form

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Please fill this form so we are able schedule the right therapist and day/time of appointment for you. This is for internal use only, and all the information you share with us will be kept confidential. If you would like for us to reach out to you for a free 15 minutes intake session to answer your queries about how this works, and learn a little bit more about each-other, please indicate so in below question where it is mentioned.

By filling out the form below, you are confirming that you have read our Terms and Conditions and Privacy Policy.

Email *

Please confirm your age before proceeding *

The patient/client is 18 years of age or above

I am the parent and/or legal guardian, in case the patient/client is a minor (below 18 years of age)

The patient/client is a minor (not 18 years of age or above)

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