Adult Initial Questionnaire

Please correct the errors described below.

The goal of this form is to give us an adequate amount of information to determine which therapist will be the best fit for you.

Once you fill this out, we will email you with next steps. Thank you for taking the time to answer our questions!

Name

State in which you reside

Phone Number

Communication Preferences

Text Ok

Email ok

Voicemail ok

Insurance Carrier

Location

Therapist requested

Allison Tuttle

Brandee Prevost

Rachel Kilgore

Katherine Ferullo

Angela Dow

The next available clinician/no preference

Are you looking for a specific day/time? Not all of our clinicians work the same schedule.

What brings you to therapy?

Are you looking for treatment for any of the following?

Trauma

Substance use

Eating Disorders

Were you referred for a specialized type of therapy?

EMDR (Eye movement Desensitization and Reprocessing

IFS (Internal Family Systems)

DBT (Dialectical Behavior Therapy)

None of the above

Anything else we should know?

Your information will be encrypted.

The goal of this form is to give us an adequate amount of information to determine which therapist will be the best fit for you.

Once you fill this out, we will email you with next steps. Thank you for taking the time to answer our questions!

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