Intake form

Name *

Email address *

What is your preferred method of contact?

Please select at least one option.

Phone

Email

Text Message

What are your primary reasons for seeking therapy?

Please select at least one option.

Anxiety

Depression

Relationship Issues

Stress Management

Personal Growth

Trauma

Have you previously attended therapy?

What is your age range?

What days of the week are you available for sessions?

Please select at least one option.

Monday

Tuesday

Wednesday

Thursday

Friday

What time of day do you prefer for sessions?

Please select at least one option.

Morning

Afternoon

Evening

Please provide any additional information or specific concerns you would like to address in therapy.

Which service or services are you interested in?

Please select at least one option.

Individual Therapy

Targeted Solution-Focused Therapy

Therapist Supervision

Therapist Training

Yoga Therapy

Additional questions or comments

Here and Now Wellness