When Life Gives You Lemons

Name:

Email:

Phone:

Have you ever been in therapy before?

Do you feel your past therapy experience was positive and therapeutic?

Do you prefer a therapist who is…

Tough, realistic

Sensitive and empathetic

No preference

Do you prefer a therapist who…

Gives a lot of feedback

Listens and validates

No preference

Do you prefer a therapist who is…

Younger

Older

No preference

Do you prefer a therapist who is a

Male

Female

No preference

Are you looking for (check all that apply):

Individual for myself

Family therapy

Couples therapy

Therapy for my child

Therapy for my teen

Are you aware that different therapists utilize different treatment modalities?

Yes

No

What therapeutic modality did you try in the past? (check all that apply)

What therapeutic modality would you like to try in the future

In the past I had therapy covered….

Through insurance

Out of pocket

Pro bono

Please list all the conditions you struggle with:

Please select the insurance you have:]

If you selected OTHER, please provide your insurance carrier below:

Member ID:

Client's Full Name:

Clients Date of Birth: