Intake form

Name *

Email address *

What is your age?

What is your gender?

What type of services are you interested in?

Please select at least one option.

Individual Counseling

Couples Counseling

Family Therapy

Group Therapy

Telehealth Services

What are your primary concerns or issues you would like to address?

Have you previously participated in any form of therapy or counseling?

If yes, please describe your previous experience(s):

Do you have any medical conditions or mental health diagnoses that we should be aware of?

How did you hear about new reflections therapeutic services?

What is your preferred method of contact?

What times are you available for appointments?

Please select at least one option.

Weekdays

Weekends

Morning

Afternoon

Evening

Which service or services are you interested in?

Please select at least one option.

Individual counseling

Couples therapy

Group therapy

Sex Therapy

Additional questions or comments