Therapy Services Eligibility Screening
Please complete this form to help us determine your eligibility for therapy services. Your responses will remain confidential and no sensitive personal information is required.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your age range?
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
What is your primary reason for seeking therapy services?
*
Anxiety or stress
Depression or mood concerns
Relationship issues
Grief or loss
Personal growth/self-improvement
Other
Have you received therapy or counseling before?
*
Yes
No
Which of the following best describes your current situation? (Select all that apply)
Currently experiencing high stress
Having trouble sleeping
Difficulty concentrating
Feeling hopeless or helpless
None of the above
Other
What days and times are you generally available for therapy sessions?
Is there anything else you would like us to know regarding your eligibility or needs?
Submit Screening
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