Client Intake Form

Get Started with Therapy

Take the first step toward better mental well-being. Fill out this form to get matched with a licensed therapist tailored to your needs.

Name

Phone Number

Date of Birth

Gender

Preferred Language

What type of therapy are you seeking?

Preferred Session Format

Preferred Therapist Gender

Availability

Have you attended therapy before?

Are you currently taking any medications for mental health?

Specify whether currently taking any medications for mental health?

How did you hear about us?

Any additional notes or preferences?

I agree to the Terms & Conditions and Privacy Policy.