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Name
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Date of Birth
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Sex and/or Associated Gender (ex. Female/Non-Binary, Female/Not Applicable, Female/Trans-Male, or Female/Male-Transitioned)
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Have you done counseling before? (select all that apply)
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If you have done counseling before, what (if anything) was positive about your past experience in counseling?
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If you have done counseling before, what (if anything) was negative about your past experience in counseling?
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In short, what is your reason for seeking counseling at this time?
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What are your individual and family/relationship goals for counseling?
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What do you spend most of your day doing? (At work, at home, caretaking?)
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What medications do you take?
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Are there any medical providers you would like to me to collaborate with on your behalf? (If so, please list the provider name(s) and phone number(s) below. (Information will not be released without a formal release of information and your signed consent f
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Are you interested in any individual counseling for yourself, or are there any types of additional support I can provide you with?
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Is there anything else important you would like me to know?
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