Initial Intake FormComplete this form to begin the process. All fields are required. Name * First Name Last Name Birth Date * Primary Language * Gender Identity Genderfluid Male Female Intersex Transgender Non-binary Prefer not to answer Bigender Preferred Pronoun(s) Select Service * 15-min Consultation - no fee Individual Therapy Trauma Therapy OCD Treatment Family Therapy 8-week Family Support Group Therapy Clinical Supervision Clinical Consultation Speaking/Training Inquiry Please provide details about your appointment. * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Agree to Terms * You are confirming that you have read, understand, and accept the Terms of Service and Privacy Policy. 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.
