Appointment Request Name * First Name Last Name DOB MM DD YYYY Email * Phone * (###) ### #### Preferred Method of Contact Phone Email Text Can we leave a message? Yes No Relationship to Client Are you presently taking any medications for mental health purposes? Yes No If yes, please list What service are you interested in? Individual Couples Family Remote What issues would you like to address in therapy?* * Addiction ADHD Anger Management Anorexia/Bulimia Anxiety Behavioral Problems (children) Betrayal Trauma Bipolar Disorder Borderline Personality Disorder Codependency Coping with Chronic Illness Coping with Chronic Pain Coping with Life Changes Depression Difficult Getting Along with others Eating Disorders Grief/Loss Infidelity LGBTQA+ Low Self- Esteem OCD Panic Attacks Parenting Issues Phobias Pregnancy Loss/Traumatic Birth Relationship Conflict Relationship Crisis Sexual Addiction Social Anxiety Stress Management Symptom Management Trauma History How did you hear about us? Message * Thank you!