Name * First Name Last Name Sex Male Female Other Age * Email * Phone (###) ### #### How did you hear about us? * Website Family/Friend Church Doctor Psychology Today Other Reason for Seeking Therapy? * Have you received therapy before? * Check all that apply * Anxiety Depression Panic Attacks Trauma/PTSD Self Harm Suicidal Thoughts ADHD Mood Swings Grief/Loss Eating Disorders Relationship Issues Have you been diagnosed with a mental health condtion? * If yes, please explain. Are you taking any medications for mental health? * If yes, please list them here. Thank you for your submission. We will reach out to you within 48 hours. .