What led you to consider therapy today?

Have you ever been in therapy before?

Name

Date of Birth

Preferred Contact Number

Email Address ( Optional )

Emergency Contact Information

What service are you looking for ?

What is your gender identity?

How do you identify ?

What is your relationship status?

Are you currently taking any medications ?

How did you hear about us ?

How would you rate your current physical health ?

How would you rate your current eating habits?

Additional Information?

What led you to consider therapy today?

Have you ever been in therapy before?

Child's Name

Child's Date of Birth

School

Parent/Guardian Name

Relationship to Child

Preferred Contact Number

Email Address ( Optional )

How did you hear about us ?

Has your child previously received any form of mental health treatment?

Is your child currently taking any medications?

Q. What service are you looking for?

Additional Information?