Therapy Intake Screening

FIRST THINGS FIRST

Full Name

Email *

Are you over 18 years old? *

Yes

Do you have a private space to complete Telehealth sessions? *

Yes

Will you be in one of the follow US states during our sessions? AL, AZ, AR, CO, CNMI, CT, DE, DC, FL, GA, ID, IL, IN, KS, KY, ME, MD, MI, MN, MO, NE, NV, NH, NJ, NC, ND, OH, OK, PA, RI, SC, TN, TX, UT, VA, WA, WV, WI, ot WY

Yes