Therapy When Life Sucks | SimplePractice

Therapy When Life Sucks Send Message

Who would be receiving care?

Me

My partner and me

Your info

First name

Last name

Email

Phone

Name you go by

Date of birth

Gender

Reason for care

What is the reason for seeking counselling?

communication issues infidelity unable to resolve conflicts build up of resentments lack of connection Other

What kind of sessions are you looking for?

In-person Virtual

Administrative

Inquiry reason

Referral source

Google search Psychology Today Friend or family member Another healthcare professional I can't remember ChatGPT

Once the office reviews your information we will contact you BY EMAIL. Please check your spam folder if you have not received a response within a couple hours

I understand that I will receive communication by email and will check my spam folder

Client Preferences

Preferred appointment times

Morning (10am to noon) Afternoon (noon to 4pm) Evening (4pm to 7pm)

Is there anything that the therapist needs to know?

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.