open house page
Register to access this page after open house ends.
Intake form as
PDF to print out
Intake form as
Word doc to fill in
Intake form
Fillable below
You can open the PDF in a new window, print it out at home, fill it in and then mail it to us, or scan & submit it here.
Download (click on above icon), fill in and save, then upload by dragging saved file over to this form below.
Cut to the chase and just fill out the form below. Submit a section after completing it. No hassling of saving nor uploading files.
Step 3: Intake step 3
Welcome to the intake form
To serve you, we need to ask you some personal questions. Knowing these details helps optimize our services to best fit your specific situation and needs.
Your information is secure with us. We are bound by ethics and law (HIPAA) to protect the privacy of your health related information. Once collected, your PHI collect here gets stored on a a stand alone external hard drive never connected to the Internet.
This is standard stuff in psychotherapy. Of course, this isn't psychotherapy, this is psychosociotherapy. In psychosociotherapy, we start at the foundation of you—your internal psychological makeup and such. We will use it to "go psychosocial" to help you confront your social situations.
In contrast to psychotherapy, this form asks you plenty of social stuff. For example, who you can rely on during a crisis, and how reliable family and others are to you.
Fill out form
Whether you use
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a printout from the PDF,
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fill in the downloaded IntakeFormA Word document, or
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use the form below,
all the questions are much the same.
Answer as many as you can, prior to our online meeting. Be sure to click the Submit button after finishing a section. Then scroll back up to read the message, before continuing to the next section.
We will then go over your responses and fill out any missing pieces. The more you provide here the less costly for everyone.
The purpose behind these questions will eventually come alive as we progress toward your stated goal(s).
Form outline. The form is organized into these sections.
Once completed you will receive an email confirmation. You are almost there. Unless something comes up, we will meet online at our first full session. Looking forward to it!
Let your journey come alive!
Continue your transformative journey here
Mouse-over this area to see the tooltip for many of the items.
Remember to click on the Submit button before answering questions in the next section. Sections not submitted will slow down the process, adding to your costs.
After you submit your information, scroll back up to see the message. Then continue to the next section.
If you're seeing another therapist, we want to let them know and coordinate our efforts for you with a business associate contract.
Why asking this?
FYI
This concludes the initial data collecting tasks, and concludes the last step until we meet by video chat. If you have any questions or concerns, do use the email and/or SMS text gadgets you see at the upper right. Let's make sure we are ready to serve your needs as soon as we start.
WORK IN PROGRESS
You’re seeing a work in progress.
Yes, I know, some content on this page is missing.
Much of this material will inevitably be changed as we go to market.
You're the market. You can help us create value with your constructive feedback.
Thank you for helping us create this meaningful service.