Client Information Page Please fill out the below secure form, which will allow for a much more thorough and useful initial discussion. Once the form is completed, I will get back to you and ask you to schedule an appointment. Name(required) Email(required) Phone number(required) Date of Birth(required) Physician diagnosed medical considerations and prescribed medications: Which, if any, of the following substances do you take on a daily or weekly basis? Alcohol Drinks per day Caffeine Milligrams per day Cigarettes Packs per day Snus Servings per day Are there any of the above substances you feel are negatively impacting you? Are you happy with your life? Do you often feel either or both of the following in a way that negatively impacts your day to day life? Anxiety Depression Do you often feel (Check all that apply): Sadness Anger Loneliness Hopeless Loved Appreciated Purposeful Impulses to do things against your best interests In your own words, how would you best describe your people, your tribe? Are you in a committed relationship? Yes No It's complicated! If so, are you pleased with it? What is their name? In one sentence, what is the biggest reason why you wish to speak with a therapist or relationship coach? If tonight, the biggest reason for why you wanted to speak to a therapist disappeared, when you woke up tomorrow what would have changed? Submit Δ Share this:TwitterFacebookLike this:Like Loading...