intake form

Below you'll find my new client intake form. Please get in touch if you have any questions, or if you're having trouble filling it out for any reason. If you prefer, we could fill this out together during a first session.

Name and pronoun

Include a few names if you prefer.

E-mail or text number

Your preferred method for follow-up.

Check here if you are age 18 or over- Unfortunately, I'm not able to work with minors at this time.

If you don't mind, could you share where you heard about my counseling services? Thanks!

What has been most helpful in past experiences of mental health services? How about the least helpful?

What positive changes are you hoping to see with the support of counseling?

What do you think of as your biggest challenges lately?

What strengths of yours may be helpful towards tackling those challenges?

What does a positive counseling relationship look like to you? What are the best ways I can support you?

For privacy reasons, I will ask the following in our first session instead of in this form:

What identities do you have that shape your experience in the world?

Do you happen to have any diagnoses you would like to share?

they/them

intake form