Intake form

Name *

Email address *

What is your primary reason for seeking therapy?

Please select at least one option.

Anxiety

Depression

Stress management

Addiction recovery

Relationship issues

Family dynamics

Trauma

Self-esteem

Autism Spectrum Disorder

Have you previously attended therapy?

Are you currently taking any medications for mental health?

What age group do you belong to?

What are your preferred days for therapy sessions?

Please select at least one option.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What time of day do you prefer for therapy sessions?

Please select at least one option.

Morning

Afternoon

Evening

Do you have any specific goals you would like to achieve through therapy?

Which service or services are you interested in?

Please select at least one option.

Individual therapy

Adolescent Treatment

Addiction recovery support

Additional questions or comments

Kirk Stafford, LMSW, LCDC, ASDCS