Name *

First Name

Last Name

Phone *

(###)

###

####

Have you been hospitalized for mental health concerns within the last 5 years? *

YES

NO

Are you currently experiencing any homicidal thoughts/ ideations? *

YES

NO

I understand that my engagement in a 30min. check-in session, is not the same as me enrolling any a full therapy program. This check-in session is not designed to treat any mental health disorder and should not be used in place of needed menta health care. If mental health services are needed, I am able to ask the therapist for steps to receive that help. *

I understand

Please Select Your Availability Preference *

We will try our best to match you with the therapist you select, however, therapists will be assigned based on the therapists ability to accommodate your schedule preference. Select all that apply.

Monday Mornings

Monday Evenings

Tuesday Mornings

Tuesday Evenings

Wednesday Mornings

Wednesday Evenings

Thursday Mornings

Thursday Evenings

Friday Mornings

Friday Evenings