Therapy Dynamics

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Date of birth

Gender

Contact Information

Phone number

Email address

Address

Can we contact you by phone, email, and voicemail?

Yes No

If no, what is your preferred method of communication?

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Which Group Are You Interested In?

Group Therapy Support is $40/session

Autistic Adults (18+) Parents of Autistic Adults Parents of Autistic Children

Non-Therapy Skills Groups $40/Session

Social Communication Skills

What are you hoping to gain from this group?

What challenges or concerns would you like help with?

Have you participated in a support group or therapy group before?

Yes No Not sure

If yes, what did you find helpful or unhelpful?

Current Mental Health Care

Are you currently working with a therapist?

Yes No

Is there anything related to your mental health that you would like for me to know?

Safety Screening

Have you experienced thoughts of harming yourself in the last month?

Yes No

Have you experienced thoughts of harming someone else in the last month?

Yes No

Recent hospitalizations in the last 6 months?

Yes No

If you answered "yes" to any of the above, we may contact you to discuss the group with you.

Group Participation

Group members are expected to attend regularly, respect the confidentiality of other members, allow others equal opportunity to participate, and treat fellow members with kindness and respect. Are you willing to follow these expectations?

Yes No

Do you have any accommodation needs that would help you participat successfully?

Is there anything else you would like us to know?

Your information will be encrypted.

Therapy Dynamics

Emergency Assistance

Client Information

Contact Information

Emergency Contact

Which Group Are You Interested In?

Current Mental Health Care

Safety Screening

Group Participation

Emergency Assistance

Kristen Math, LPCC-S

Therapy Dynamics, PLLC