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What is the reason for seeking care? Select as many as applicable.

Anxiety/Depression Relationship/Marital issues Sexuality and Intimacy issues Gender Identity related issues

What kind of care is being sought?

Individual Therapy Couples Therapy Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons in the past Attempted suicide in the past

Describe your current living situation. Do you live alone, with others. With family, etc...

What are your goals for counseling?

Limited to 600 characters

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