Name
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First Name
Last Name
Email
*
Phone
*
(###)
###
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Preferred contact method
*
Appointment Type
Concerns you'd like to address in therapy
*
Check all that apply.
If you selected "other", please describe.
Which therapeutic approach are you looking for?
*
Are you currently engaged in a different treatment program? (Rehabilitation, inpatient, outpatient, or psychiatric medication management?) Please provide a few details.
*
Are there any identity preferences for your preferred therapist? (Racial, Sex/Gender, Sexual Orientation, etc.)
*
Will you be using insurance to pay for therapy, or will you be paying out of pocket?
*
Insurance provider name
Is there anything else you want us to know beforehand?
SMS Consent
By submitting, you agree to receive text messages at the provided number from Gaining Ground Mental Health Counseling. Messaging frequency varies, and standard message and data rates may apply. You have the right to opt-out of receiving messages at any time. To opt-out, reply “STOP” to any text message you receive from us. Reply “HELP” for assistance.
