Therapy Evaluation Plan Estimator
Help us understand your needs to estimate an optimal therapy plan tailored for you.
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 primary reason for seeking therapy?
*
Please select the issues or concerns you would like to address in therapy.
*
Anxiety
Depression
Stress Management
Relationship Issues
Grief/Loss
Self-Esteem
Other
How would you rate the severity of your main concern?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
How often do you experience symptoms related to your concern?
*
Rarely
Occasionally
Frequently
Almost always
Have you attended therapy before?
*
Yes
No
Preferred type(s) of therapy (if any):
Cognitive Behavioral Therapy (CBT)
Psychodynamic Therapy
Mindfulness-Based Therapy
Solution-Focused Therapy
Family/Couples Therapy
Other
How many sessions per month would you prefer?
1 session
2 sessions
3-4 sessions
More than 4 sessions
What are your main goals for therapy?
*
Please rate your motivation to participate in therapy.
1
2
3
4
5
Additional comments or information you would like to share:
Estimate Plan
Should be Empty: