Initial Intake FormComplete this form to begin the process. All fields are required. Name * First Name Last Name Birth Date * Email * Primary Language * Gender Identity Genderfluid Male Female Intersex Transgender Non-binary Prefer not to answer Bigender Preferred Pronoun(s) Preferred Contact Information * Call Email Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Select Service * 15-min Discovery Videocall - no fee Individual Therapy IFS/EMDR/PE Therapy OCD Treatment ERP Integrative OCD Treatment IFS-ERP, ACT Family Therapy 8-week Family Support Group Therapy Clinical Supervision Clinical Consultation Speaking/Training Inquiry Please provide details about your appointment. * Screener * Are you currently experiencing thoughts of harming yourself or others? Yes No Have you ever been hospitalized for mental health reasons? * Yes No Prefer not to answer right now Are you currently working with another therapist, psychiatrist, or other provider? * Yes No Private Pay Practice JLPsychotherapy Counseling Training is a Private Pay Practice only. Yes, I have reviewed rates and understand Agree to Terms * You are confirming that you have read, understand, and accept the Terms of Service and Privacy Policy. NOTICE: Thank you for taking such a significant first step in filling out this form!We will reach out to you within 2-3 business days.
