Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone (###) ### #### Where do you live? (###) ### #### Will you be applying for sliding scale payment? Yes No Not sure How often do you want to meet online for therapy? Never Only if needed 50/50 Most of the time Always How often do you want to meet outside for therapy? Never Occasionally As much as possible Not sure What services are you interested in? Individual Couples Family Group Have you ever seen a therapist before? If so, for how long? No, first timer Yes, for more than a month Yes, for more than six months Yes, for over a year How did you hear about True Wild? PsychologyToday Web search Flyer/business card Friend/Family Therapist referral Please describe what's bringing you to therapy, including any issues you'd like to work on, goals, expectations, questions, etc. * Thank you! New Client Submission If you’d like to work with me please fill out the below form and I will respond within 48 working hours
