Name

First Name

Last Name

Date *

MM

DD

YYYY

Symptoms

{Optional} Please check of symptoms you are experiencing:

Anxiety (constant worry)

Panic attacks (feeling like you can't breathe or calm down)

Depression

Crying spells

Appetite changes

Concentration issues

Anger issues

Irritability

Avoidance

Sleeping problems

Feeling on edge

Lack of interest in usual activities

Substance use/abuse

Relationship struggles

Please email me:

Check all that apply. Please elaborate on recommendations needed in the additional information section. The more specific information I have about your needs, the better my resources will be. If you'd like a referral to another therapist, please indicate which insurance you have (or will have 1/1/21), private pay, or sliding scale fee needed.

Referrals to other practitioners

Coping skills for anxiety

Coping with COVID-19

A referral to a higher level of care

Book recommendations

Support group recommendations

Emergency *

I understand that if I am having thoughts of harming myself or others that I need to call 911 or go to my nearest emergency room. This form is not a consent nor a guarantee for treatment.

Yes, I understand