Intake Request Form - Healing Beyond Words

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Email *

Legal Name (if different)

Phone Number *

Client Date of Birth *

What is your preferred modality of therapy? *

Client Name *

Client Pronouns

Would you prefer communication with me via Email or Phone? *

What type of therapy are you pursuing? *

Who referred you to my practice? *

What are you hoping to address in therapy? *

Have you pursued therapy services in the past? If so, for what reason(s)? *

Are you currently, or have you in the past, experienced suicidal thoughts or desire to harm yourself? *

Have you been hospitalized for a mental health concern? If so, when and for what? *

Do you have any previous mental health diagnoses? If so, what? *

Are you currently on any psychotropic medications? If so, what medications? *

Do you have a history of eating disorders or disordered eating behavior? *

Do you have a history of addiction (behavioral or substance) or substance abuse? *

If you are requesting services for a child, please provide guardian(s)/parent(s) name *

How are you planning to pay for services? *

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What is your street address *

Address Line 1

Address Line 2

City

State

Zip Code

Thank you for considering my services for sliding scale. I have a limited number of sliding scale openings at any given time. My typical fess is $150/session with sliding scale openings including any amount between $70 - $140.

What amount per session is sustainable for you to pay? *

Intake Request Form – Healing Beyond Words, LLC