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Psychotherapy Intake

Before we meet

A few things so we can meet you prepared.

Please take the time to fill our intake form before arriving. The more you can share before we meet, the more prepared we can be — and the less of your session we spend on discovery. Need help with a question? Ask our AI Wellness Advisor down below.

You

How should we reach you?

Someone we can reach if needed. Optional if that feels like too much tonight.

What brings you

Describe your current concern or challenge and the reason for seeking therapy *

Body & safety

A few facts that help us work safely.

Have you received therapy or counseling before? *

Are you currently taking any medications? *

Do you have any medical conditions or allergies? *

Psychological history

Have you ever been diagnosed with a mental health disorder? *

Have you ever attempted or considered self-harm or suicide? *

Personal history

Are there any significant life events or traumas you’d like to share that might be contributing to your current condition?

If relevant to your current condition, please provide a brief overview of your family and upbringing and/or your current living and social circumstances.

Therapy goals

What are your primary goals for therapy, and what do you hope to achieve through this process? *

Consent

A simple agreement, then you’re done.

Typing your name is a legally binding electronic signature, equivalent to a handwritten signature.

Received

Thank you. Health & Light has what we need to begin.

If you want to reach us directly, call or text 754-273-5510.

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*Estas declaraciones no han sido evaluadas por la Administración de Alimentos y Medicamentos. Estos productos y/o servicios no están destinados a diagnosticar, tratar, curar o prevenir ninguna enfermedad.

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