Contact Form

First Name

Last Name

Email Address

Okay to email?

Phone

Okay to leave voicemail messages?

Street Address, City, State, Zip

Emergency Contact Name

Emergency Contact Phone Number

Relationship to Client

Client Date of Birth

Gender GenderMaleFemaleOther

Relationship Status Relationship StatusSingleCohabitatingMarriedSeparatedDivorcedOther

Ethnicity

Employment Status Employment StatusEmployed Full TimeEmployed Part TimeUnemployedNot Seeking Outside Employment

Approximate Annual Income

I have a medical provider I see at least once a year.

I am under the care of a psychiatrist.

What led you to seek counseling today?

About how long have you been struggling with this/these issue(s)?

What part does faith, religion, or spirituality play in your life? What part does faith, religion, or spirituality play in your life?I consider myself very religious/spiritualI am somewhat religious/spiritualI am agnostic or undecided about spiritualityI consider myself an atheist

Harming Harming Have you ever had thoughts of harming yourself or others?

If yes, please explain

Are you experiencing any physical symptoms (pain, under/overeating, etc.)

If yes, please explain

Are there any significant past or present mental health issues that we should be aware of not mentioned above?

If yes, please explain

Is there anything else you would like me to know before we schedule a meeting?

I prefer to meet using Apple's FaceTime. I prefer to meet using Google Meet. (Great for PC users) I prefer to meet via a phone call.