Quick Get to Know You

Are you completing this form for someone else? *
If you are completing this form for someone else please provide your name and relationship to the person in the box below. If you would like us to contact you first, please state this in the box below and include your phone number and email address. All other fields should be completed with the future client's information.
Are you interested in Individual or Group Therapy? *
Please select at least one option, selecting multiple is fine. Group listings are on our Current Groups Page
Client Name *
Client Name
Please Supply Month/Day/Year we use this to make sure you are in network with us
This will help us make sure we identify you correctly. ex) She/Her/Hers, they/them/theirs
Can we leave you a voicemail, text, or email message on this number and email address? *
It is usually a letter followed by six numbers
Currently we do not accept Medicare
Our full rate is $125/hr, we try to a accommodate people with much lower rates. We ask you to let us know now or over the phone what you feel you are able to afford in a month and we will do our best job to work with it. Please know we try to accommodate for many people and will do our best to help if we are able.
If yes, please explain
If so please describe what that looked like and how it looks currently
If so when and did you have follow up treatment of any kind?
What are the current medications and the dosage you are taking
How was that experience?
(brief description)
We currently are located on the second floor, but do have an office we can use on the 1st floor if needed
This could be a recent event or how you might identify
This Section is for Couples or Family Services Only
Please complete the below field for all persons who will be participating in sessions.
Please provide the First & Last Name, Birthdate, and Gender Pronouns (if you wish to share), and Medicaid numbers if applicable for additional Clients who will attend sessions.
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. If you are completing this form for a couple or family please use the initial “client” fields for the main point of contact and use the couple/family additional information field at the end of the form to add personal information for everyone else who will be joining the sessions. In addition for couple/family, please complete fields with information for all attending members to the best of your ability starting with the question: “Is there any violence in your home currently or in past relationships?”. 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. We have a two session intake process. Therapy itself will feel a bit different than the first contact which is a history gathering appointment. Please know that you may not work with the therapist who completes your intake. After completing the two sessions we will determine if we are the right fit for you and we will offer you other referrals if we are not.