Therapy Assessment Request Form
Please complete this Therapy Assessment Request Form to help us understand your needs and plan your intake. All questions are structured for clarity and comfort.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
No Preference
What is your primary reason for seeking therapy?
*
Please Select
Stress or Anxiety
Depression or Low Mood
Relationship Issues
Personal Growth
Work or Academic Challenges
Other
How would you rate your overall well-being in the past month?
*
1
2
3
4
5
How urgent is your need for therapy?
*
Immediate (within 1 week)
Soon (within 2-4 weeks)
Flexible (no specific timeline)
Preferred Session Type
*
In-Person
Online/Virtual
No Preference
Have you attended therapy before?
*
Yes
No
What is your main goal or expectation from therapy?
Submit Request
Should be Empty: