Name *

First Name

Last Name

Phone *

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Date of Birth *

Date of Birth is needed to verify insurance benefits.

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DD

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Preferred Appointment Day and Time *

Check all that apply.

Weekdays from 8am-11am

Weekdays from 11am-2pm

Weekdays from 2pm-5pm

Weekdays from 5pm-9pm

Reasons for Appointment

Please check all that apply. If you do not see your reason for attending therapy listed, or want to expand on any of the items listed, please do so below in the message box.

Anger Management

Anxiety

Body Image

Chronic Pain + Illness

Cultural Concerns

Depression

Eating Disorders

EMDR

Grief

Health Coaching

Identity Development

Life Transitions

OCD

Relationship Issues

Self-Esteem

Sport + Performance Psychology

Stress Management

Substance Use + Addiction

Suicide + Self-Harm

Trauma + PTSD

Women's Issues

Other