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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?
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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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