Initial Screening Form
Welcome! Thank you for your interest in beginning therapy. Please fill out to the best of your ability. After submitting, please allow up to 24 hours for a response. Thank you!
Name:
*
E-mail Address:
*
How would you like me to contact you?
*
Please Select
Email
Phone
Email Address:
Phone number:
What brings you to therapy at this time? Mark as many as you'd like.
Depression
Anxiety
Covid-19 Related Stress
Phase of life transition (new parent, divorce, separation, career, etc.)
Women's Health
Chronic Illness
Pregnancy or Postpartum
Grief/Loss
Trauma - PTSD, Complex Trauma, Vicarious
Birth Trauma
Relationship with food or Eating Disorder (anorexia, bulimia, binge eating, restrictive and avoidant eating, orthorexia)
OCD
Other
Have you ever participated in therapy or mental health care of any kind (individual or group)?
No
Yes
I don't know
Do you heave health insurance?
No
Yes
I don't know
What insurance do you have?
Aetna
Cigna
Oxford
Optum
United Healthcare
Other
Please share your therapy goals:
Please use this space to list any questions, comments or concerns:
Submit
Should be Empty: