Intake form

Name *

Email address *

What is your age?

What is your gender?

Which therapy services are you interested in?

Please select at least one option.

Individual Therapy

Group Therapy

Couples Therapy

Family Therapy

What mental health issues are you currently experiencing?

Please select at least one option.

Depression

Anxiety

Stress

PTSD

OCD

Have you previously received therapy?

What is your highest level of education completed?

What is your occupation?

How did you hear about us?

Please select at least one option.

Social Media

Word of Mouth

Search Engine

What are your goals for therapy?

Do you have any medical conditions we should be aware of?

Additional questions or comments

InsightfulMinds