Intake form

Name *

Email address *

What type of therapy are you seeking?

Please select at least one option.

Individual Therapy

Couples Therapy

Family Therapy

What are your preferred days for therapy sessions?

Please select at least one option.

Monday

Tuesday

Wednesday

Thursday

Friday

What are your preferred times for therapy sessions?

Please select at least one option.

Morning

Afternoon

Evening

Have you previously attended therapy?

If yes, what was the focus of your previous therapy?

What are your primary concerns or goals for therapy?

Do you identify as part of any marginalized communities?

Please select at least one option.

LGBTQ+

Racial or Ethnic Minority

Immigrant

What is your age range?

What is your preferred method of communication?

How did you hear about us?

Which service or services are you interested in?

Please select at least one option.

Individual therapy

Couples therapy

Family therapy

Ketamine Therapy

EMDR

Additional questions or comments

EFTING Emotionally Focused Therapy by Ingrid