Name * First Name Last Name Preferred Pronouns * He/Him She/Her They/Them Other Email * Phone (###) ### #### Preferred form of contact Phone Email Either Date of Birth * MM DD YYYY What type(s) of services are you interested in? * Anxiety Therapy Depression Therapy EMDR Trauma Focused Care ADHD Therapy Acceptance and Commitment Therapy Identity Therapy Relationship Therapy Sex Therapy Are you interested in couples therapy? * Yes Yes, in addition to individual Maybe No Are you currently experiencing or have you previously experienced any of the following * Important Note: This form is not a substitute for crisis support. If you are feeling unsafe, or experiencing a psychiatric emergency, please call 988 or visit your local emergency room. Thoughts of hurting yourself or someone else Active substance abuse Legal issues (arrest, DUI, DCYF involvement, etc.) Not applicable If you answered yes to the question above, please provide us with some background information to further assist us. Have you received counseling or therapy in the past? * Yes No Not sure Is there a specific provider you are interested in working with? * Please note: Not all of our clinicians currently have openings, however this information is helpful to us in understanding what you are looking for in a provider and we will work to offer your the closest match possible. Michelle Payton , LCWS Christina Mathieson, LMFT (currently has a waitlist) I'm open regarding matching How did you hear about us? * Google ZenCare Psychology Today Podcast or Blog Friend or Family Member Healthcare Provider Referral Other Are there any specific scheduling needs we should consider when setting your appointment time (i.e. mornings before 12pm, specific days of the week, etc.)? * Thank you!