New Client Questionnaire

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Name(Required)

First Last

Email(Required)

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1. What are you hoping to work on in therapy?(Required)

Select any that apply

Anxiety or stress

Depression or low mood

ADHD or executive functioning difficulties

Autism-related support

Life transitions (e.g., career, relationships, parenthood)

Trauma or PTSD

Relationship challenges

Parenting support

LGBTQIA+ identity exploration, support, or related concerns

Other

You selected Other

Please describe what you hope to work on in therapy.

2. Are you seeking therapy for yourself, your child, or another family member?(Required)

Select any that apply

Myself

My child

My partner

My family

Other

You selected Other

Please describe

3. Have you worked with a therapist before?(Required)

Please select one

Yes, within the last year

Yes, but not recently

No, this is my first time

You selected Yes

If yes, what worked well for you in therapy? If not, what do you hope to get out of it?

You selected Yes

If yes, what worked well for you in therapy? If not, what do you hope to get out of it?

4. Do you have a specific goal or focus for therapy?

5. How would you prefer to pay for therapy?(Required)

Please select one

Insurance

Private pay

Not sure yet

Provider and Plan Info

Please enter provider & plan info

6. I offer therapy services via telehealth and in-person in Broomfield. Which do you prefer?(Required)

Please select one

Telehealth only

In-person only

Open to either

7. Is your availability limited to 3:00 PM or later?(Required)

Please select one

Yes

Yes - please list the times you are available)

If your availability is limited to 3:00 PM or later, please note that my current openings during those times are limited, and you may need to go on a waitlist. If you are looking to start therapy more urgently, I encourage you to schedule a consultation instead of an intake, so we can explore your needs and I can provide alternate referral options if helpful.

8. Do you have any urgent safety concerns, including thoughts of harming yourself or others?(Required)

Please select one

Yes

If you are in immediate distress, please call 988 to reach Colorado Crisis Services, or go to the nearest emergency room.

9. Is there anything else you’d like me to know before scheduling?

📌 Confidentiality Notice:(Required)

This form is sent to my business Gmail account, which is a good place for general messages and logistical questions but is not a HIPAA-compliant platform for sharing sensitive mental health information. If you prefer to discuss personal details in a more secure way, I encourage you to schedule a consultation, where we can talk privately.

I have read and agreed to the notice above.

Name

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Questionnaire

Next Steps: Sync an Email Add-On

Ready to Start Your Journey to
Better Mental Health?

Site Links

Additional Information

Questionnaire

New Client Questionnaire

Next Steps: Sync an Email Add-On

Ready to Start Your Journey toBetter Mental Health?

Site Links

Additional Information

Ready to Start Your Journey to
Better Mental Health?