Name *

First Name

Last Name

Phone *

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Current symptoms? *

Anxious, nervous, on edge

Depressed, feeling down, lack of interest in things

Intense negative emotions (anger, shame, guilt)

Flashbacks, nightmares, dissociation

Trouble concentrating, staying on task, low of follow through with responsibilities

Risky behavior (substance use, gambling, anonymous/unsafe sex practices, spending a lot of money, getting in to physical fights)

Relationship issues (partner, family, friends)

Sleep disturbances (too little, too much, waking up frequently)

Physical ailments (aches, pains, chronic medical conditions)

Avoidant behavior (socially, emotionally, physically)

Other: (Please add details in additional information section)

What do you want to get out of your sessions? *

Process stressful events

Problem-solve for solutions

Build skills (mindfulness, coping, relaxation, communication, conflict resolution, boundaries, etc.)

Process trauma

Explore options for symptom management

Maintenance and prevention planning

Learn about mental health and wellness

What are you looking for in a therapist? *

A safe person to process my emotions and vulnerabilities with

Someone who will challenge me

Someone to brainstorm ideas with

Someone who has experience and success treating my symptoms

Someone who can teach me a structured way to manage my thoughts, emotions, and behaviors

Something else: (Please add details in additional information section)