Intake form

Help us serve you better

Name *

Email address *

What is your age?

What are your preferred methods of communication?

Please select at least one option.

Phone

Text Message

Have you previously attended therapy?

What are your primary concerns or issues you would like to address?

What is your preferred appointment type?

Do you have any specific goals for therapy?

What is your current mental health status?

Do you have any medical conditions or medications that may affect your therapy?

Additional questions or comments

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Integration Counseling