Tell me a little more.

Please take a moment to fill out the following information to ensure that I am the best mental health provider to help you feel better.

Name

First Name

Last Name

Phone

(###)

###

####

How did you find us?

How old are you?

I am:

If you are employed, what is your occupation and who is your employer?

If you are a student, what school do you attend?

Are you currently being treated for any medical and/or psychiatric conditions?

If yes, please list the medical and/or psychiatric conditions you are being treated for.

For example, anxiety, asthma, depression, diabetes, hypertension...

Please list current medications, dosages and length of time you have been taking.

Are you currently seeing a therapist?

If yes, what is therapist's name?

Do you have a history of self harm or suicide attempts?

Have you been hospitalized for mental health or substance abuse reasons?

If so, how many times, where and when?

I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system.

Your mental wellness is our priority. ♡