Group Therapy Quick Get to Know You

Group Intake Information
After you fill out this form a therapist will call you for a quick 15 minute consult before setting up an intake with you. Everything you discuss on this form, or in the future with a Whole Connection therapist, will be kept confidential and stored only in our locked locations. Your privacy is important to us, but we are also trying to make sure that our services are a good fit for you. Please be aware when filling out the form, that we are mandatory reporters for child and elder (70+) abuse and neglect as well for active suicidal or homicidal plans. Please know we are on the second floor and there is no elevator, if going up stairs would be difficult please let us know. We will reach back out to you in 24-48 hours. We start with a 10-15 minute phone intake with one of our clinicians. At this time we can schedule our intake sessions. We have a two session intake process which are billed as normal sessions. We will work with you to find the best fit possible in a therapist. If you are in a crisis please go to, or call 1-844-493-8255
Preferred Name *
Preferred Name
Date of Birth *
Date of Birth
Best phone number to reach you at *
Best phone number to reach you at
Can we leave you a voicemail, text, or email message on this number and email address? *
Please know that we do not accept Medicare, only Medicaid
This could be a recent event or how you might identify