Modern Mindful Therapy | SimplePractice

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Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What is your reason for seeking care?

Anxiety Attention difficulties Behavioral issues Depression Grief Relationship issues Perinatal support (IVF, prenatal, and postpartum) Parenting and intergenerational dynamics Relational/Complex trauma Recent or acute traumatic incident Cross-cultural dynamics Substance use Other

What kind of care are you looking for?

Psychotherapy Collaborative Treatment ("I have a therapist and want to supplement treatment with EMDR.") Clinical Supervision/Consultation (for therapists only) Not sure

What is your previous experience with mental health treatment?

First time in therapy In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past None of these apply Prefer to share during phone consult

Administrative

Inquiry reason

Referral source

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Client Preferences

Preferred modality

What would you like me to know?

For example: what you'd like to focus on, interest in a specific modality, how does teletherapy work, etc.

Limited to 600 characters

Preferred appointment days

Mondays Tuesdays Wednesdays Fridays

Preferred appointment times

Mornings (9am-11am) Afternoons (12pm-3pm)

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.