Intake form

Name *

Email address *

What is your date of birth?

What is your gender?

What is your preferred method of communication?

Please select at least one option.

Email

Phone

Text

What are your primary concerns or issues you would like to address?

Please select at least one option.

Anxiety

Depression

Stress

Relationship Issues

Trauma

Self-esteem

Have you received counseling or therapy in the past?

If yes, what type of therapy or counseling did you receive?

Are you currently taking any medication related to mental health?

If yes, please specify the medication name(s).

Do you have any medical conditions that we should be aware of?

What are your goals for counseling?

How did you hear about us?

Which service or services are you interested in?

Please select at least one option.

Individual counseling

Couples counseling

Family therapy

Additional questions or comments

The Way Counseling LLC