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What is the reason for seeking care? check all that apply

Nervous System Dysregulation Emotional Reactivity / Overwhelm Burnout and Exhaustion Functional Freeze / Stuck in Survival Mode Chronic Anxiety and Stress Chronic Overthinking Attachment / Relational Issues Boundaries / People-pleasing Other

What kind of care is being sought?

Individual Psychotherapy Group Therapy Couples Counseling Family Therapy

Tell me about your Mental Health journey

New - no previous engagement in therapeutic services / medication Currently seeking a new therapist Currently prescribed psychiatric medication History of therapeutic engagement - more than 12 months ago History of Medication Management - more than 12 months ago Hospitalized for mental health reasons - within 6 months Hospitalized for mental health reasons - more than 12 months ago History of suicide attempt(s) Known neurologic or genetic disorder

Practice Restrictions & Limitations

All Court-ordered treatment requests will be referred to alternate provider

Court ordered / probation / legal requirement Requested by attorney or part of legal case Custody or divorce proceedings Pending legal proceedings I am NOT seeking therapy for any of the aforementioned reasons.

This practice is not equipped for crisis treatment

For crisis support call or text 988 or go to the nearest emergency room

Active suicidal thoughts within the past 12 months Thoughts of harming someone else within the past 12 months I am NOT currently experiencing any thoughts of harm to self or others.

This practice is not equipped for intensive psychiatric after-care.

Contact your Insurance provider for IOP, PHP and inpatient resources

Recent suicide attempt within the past 12 months Severe substance dependence within the past 12 months Recent psychiatric hospitalization within the past 12 months I am NOT seeking therapeutic after-care for any of the aforementioned reasons or the like.

Documentations Restrictions ~ Requires no less than 20 session over 6 months

Documentation is not guaranteed

Disability claims Emotional support animal letters Work leave or legal accommodation Required if seeking documentation - I understand, participation in therapy does not automatically establish eligibility for documentation,. I am NOT seeking therapy for any of the aforementioned documentation requests.

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