Client Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Presenting issues *

Addiction

Alcohol use

Anxiety

Attention-deficit/hyperactivity disorder

Chronic pain/illness

Couples counseling

Depression

Disordered eating

Dissociation

Grief/loss

Life transitions

Low self-esteem/self-worth

Nightmares

Obsessive-compulsive disorder

Panic attacks

Personality disorder

Phobias/fears

Posttraumatic stress disorder

Self-harming behaviors

Sexual identity/expression

Sleep difficulties

Stress

Suicidal thoughts

Trauma

Other (please include in the text box below)

Virtual or in-person therapy? *

Please note that if you are using your insurance that the mode of therapy offered may depend on what your insurance covers.

Virtual/Telehealth

In-person

No preference