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About
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Individual Counseling
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Parenting support
Youth Counseling
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Clients portal
Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Menu
Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Appointment
Clients Portal
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Personal Information
Full Name:
*
Date of Birth:
*
Phone Number
*
Email Address
*
Preferred Contact Method (Phone/Email):
*
Street Address
*
Apartment, suite, etc
City
State
ZIP / Postal Code
Current Concerns
What brings you to therapy at this time? (Please describe briefly):
*
How long have these concerns been present?
*
What are your goals or hopes for therapy?
*
Have you received therapy before? If yes, please provide a brief summary of past experiences:
*
Mental and Physical Health
Are you currently experiencing any of the following (check all that apply):
Anxiety (e.g., excessive worry, restlessness, panic attacks)
Depression (e.g., persistent sadness, lack of energy, hopelessness)
Relationship Issues (e.g., conflicts, communication problems)
Stress (e.g., feeling overwhelmed, difficulty coping)
Trauma (e.g., flashbacks, hypervigilance, emotional numbness)
Grief/Loss (e.g., difficulty processing loss, feelings of emptiness)
Identity or Gender-Related Concerns (e.g., questioning identity, feeling unsupported)
Anger or Irritability (e.g., frequent outbursts, difficulty managing anger)
Sleep Issues (e.g., insomnia, nightmares, difficulty staying asleep)
Eating or Body Image Concerns (e.g., disordered eating, body dissatisfaction)
Low Self-Esteem (e.g., negative self-talk, feeling unworthy)
Other
Do you have any medical conditions or physical health concerns that may affect your mental health?
*
Are you currently taking any medications related to your mental health? (If yes, please list):
*
Lifestyle and Support
What are some sources of support in your life (e.g., friends, family, community, hobbies)?
*
Are there any major life changes or stressors you are currently experiencing?
*
Additional Information
Is there anything else you’d like your therapist to know before your first session?
*
Submit
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