Services

Name*

First Last

Email*

Phone*

What has you seeking out our services?*

Zoom or phone call for no-commitment informational meeting?*

Zoom
Phone call

Please list of several specific days/times (20 min) you currently have available for a call or zoom?*

Optional additional information to provide:

Please note the below form is not HIPAA safe; all HIPAA safe forms are completed through our secure portal through TherapyAppointment. That said, all information provided here will still be kept private (except for instances of mandatory reporting), even though you will not be considered a "client" until we have our intake appointment.

What services are you/the potential new client seeking?

Psychotherapy: addressing concerns such as anxiety, trauma, grief, relationships, difficult life transitions, and other challenges
Mental performance coaching: restoring performance, enhancing performance to new heights, mental skills training for individuals and teams (not insurance reimbursable)
Biofeedback only: Become more able to self-regulate physiological stress responses, assisted by computerized awareness building/training techniques
Group or team workshop(s): can offer a wide variety of topics
Mentorship
Other:

If other, please explain:

If workshop(s), what do you envision and do you know your budget?

What specific questions do you have for us?

Referral Source

Word of mouth
Website
Social media
Other:

If word of mouth, who referred you to us?

If other, please explain:

Are you (or the person you're completing this form for) a new potential or returning client?

New
Returning

Are you/the client a(n):

Individual
Couple
Family
Team
Other:

If other, please explain:

Client relationship to you:

Self
Spouse
Child/dependent
Other:

If other, please explain:

Client name (if not you)

Client age

How receptive are they to receiving help at this time?

Have you (or the potential new client) done therapy or mental performance coaching before?

Yes
No

What was helpful and/or what was not helpful or not?

Is there anything else you think we should know at this time?

Optional additional information to provide:

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SERVICES

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