intake form

Talk about it. Se habla español.

Name

Your Age

Phone Number

Is it okay for us to leave a message at this number?

Is it okay for us to text this number?

Availability for Sessions

What brings you to therapy?

Is there an immediate medical or psychological crisis?
YESNO

Legally, we need to ask if you are currently a danger to yourself or others?
YESNO

Are you involved in the court system or a DCFS Case?
YESNO

What else would you like us to know to help you find the best therapeutic fits?