Let’s Begin Therapy.

Today's Date

MM

DD

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Name *

First Name

Last Name

Phone *

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Who needs therapy services? *

Self

Family Member

Friend

Other

If referring someone other than yourself, please provide their first and last name (if under 18, please provide parent/guardian name):

First Name

Last Name

Reason for Therapy (check all that apply): *

Easily Agitated/Irritable

Low Self-Esteem

Withdrawn

Grief/Loss

Substance Abuse

Family/Couple

Relationships

Peer Conflict/Bullies/Gets Bullied

Stress Management

Struggling with a Transition (School, College, Employment)

Weight Gain/Weight Loss

Sleep (too much or too little)

Short Attention Span/Impulsive

Defies Rules/Destructive

Problem Gambling

Other