Initial Screening

First name

Last name OR Last initial

Pronouns

Email address

Phone number

Do I have permission to email you?

Yes No

Do I have permission to leave you a voicemail?

Yes No

Where do you typically live? (City, State)

Do you have a preference for telehealth video appointments, in-person appointments (in Raleigh, NC), or either way?

Telehealth video appointments In-person appointments Either way

Are you seeking therapy for a...

Child (under 10) Preteen (10-12) Teen (13-17) Young adult (18-25) Adult (26-64) Elder adult (65+) Couple (dating, engaged, or married) Family (multiple members of family)

Do you hope to use insurance to help pay for therapy? If so, what’s the name of your insurance company? (e.g. BCBS, Aetna, Cigna, United, etc.)

In general, what DAYS OF THE WEEK could work for you for appointments?

Monday

Tuesday

Wednesday

Thursday

Friday

None of these

In general, what TIMES OF DAY could work for you for appointments?

Morning (9:00am-12noon)

Early afternoon (12noon-3:00pm)

Late afternoon (3:00pm-5:00pm)

None of these

If you had to summarize in just 1-2 sentences your main reason(s) for seeking therapy at this time, what would you say?

Do you have any questions for me? If so, I'll try to reach out to you and see if I'm able to answer your questions.

If I'm unable to accept new clients at this time, would you like to stay on my waiting list? Note: If on a waiting list, I encourage you to keep looking for a therapist who could see you sooner rather than later. This is especially true if you or your loved ones have been worried about your safety. In case of crisis, please call 911 for emergency services, 988 for Suicide & Crisis Lifeline, or visit your nearest emergency room.

Yes No

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