New Client Request Form

First Name

Last Name

Date of Birth

Age

Email address

Phone number

Please complete the following items as thoroughly and honestly as possible so that I may best assist you in meeting your wellness goals. Due to my intentionally small practice I accept new clients on a case by case basis according to fit with my practice model, specialty areas and current availability. In the event that I do not currently have new client availability or that your needs are best served by another provider/service, I will send you that information directly.

Please indicate type of service(s) you are seeking check all that apply | see website for detailed service descriptions

Private therapy sessions

Private career counseling sessions

Private coaching sessions

Psychological evaluation

Other (please describe below)

Please indicate the session styles you are interested in check all that apply | see website for detailed session style descriptions

Stride - walk and talk sessions (outdoor)

available for therapy, career counseling and coaching services

Flow - mindful movement sessions (indoor or outdoor)

available for therapy, career counseling and coaching services

Traditional - in office, non-movement integrated sessions

available for all service types

Please provide a brief description of your current concerns

Please describe your goals for our work together

Please describe any of the above experiences that you checked if you have not already done so. Is there any other information you think is helpful for me to know? Any questions you have for me?

How did you hear about Harbor Wellness/Dr. Stodard? check all that apply

Doctor referred

Other professional referred

Friend/family recommended

Website

Social media

Other

Need immediate support?

If you are in crisis or need immediate support, call or text 988 to reach the National Suicide & Crisis Lifeline. Trained counselors are available 24/7 to provide support and connect you to resources if necessary.

If you need assistance managing a behavioral or mental health crisis contact The Mobile Response Team (MRT) which provides 24/7 intervention and support to all individuals in Escambia, Santa Rosa, Okaloosa and Walton Counties. Call 866-517-7766. The team will assess your concerns via phone triage and can dispatch a team to your location if needed.

If you are experiencing an emergency, call 911 or go to the nearest emergency department.

Your information will be encrypted.

New Client Request Form

Dr. Megan M. Stodard

Psychologist, Harbor Wellness