Intake form

Name *

Email address *

What is your age?

What is your gender?

What is your current occupation?

What brings you to seek therapy?

Please select at least one option.

Anxiety

Depression

Stress

Relationship issues

Trauma

Have you previously sought therapy?

Do you have any previous mental health diagnoses?

Please select at least one option.

Anxiety Disorder

Depressive Disorder

Bipolar Disorder

PTSD

None

Are you currently taking any medication for mental health?

Do you have a support system in place?

What is your preferred mode of communication?

How did you hear about us?

Additional questions or comments

Please confirm that you are not a robot.

Flora Bot