Name * First Name Last Name Email * Phone Number * May we leave you a message? * Yes No What is your preferred method for scheduling? * Email Text message Phone call What setting do you prefer for therapy? * In Person Virtual Who are you contacting us for? * Myself My child Other Primary Client Name * (If you are filling this out for someone else, please include their name here.) What is your relationship to the primary client * Self Parent Other Pronouns * What kind of therapy are you seeking? * Adult Individual Therapy Adolescent Individual Therapy Child Individual Therapy Parenting Support / coaching Nervous System Healing Intensive The qualities I would like my therapist to have are? * What topics would you like to explore in therapy? * Anxiety / worry Depression / low mood Low self-esteem Grief / loss Anger / Low frustration tolerance Trauma (adult onset) Trauma (childhood) Relationships Family conflict Adolescent concerns Parenting support Postpartum Identity exploration LGBTQIA+ Cultural experiences Music therapy Creative arts therapy Nervous system healing Mindfulness and meditation Shame resilience and self-compassion Life transitions Stress Coping skills ADHD PTSD Other Do you have specific scheduling needs * Please select as many as possible to help with scheduling I have a flexible schedule Weekday mornings Weekday afternoons Weekday evenings How often would you like to meet? * Weekly Twice a month Monthly Is there anything else you would like us to know at this time? * Thank you!