Start Your Journey

Name *

First Name

Last Name

Phone *

(###)

###

####

Client Name *

First Name

Last Name

Client Date of Birth *

For anyone under 18, we require an initial parent appointment.

MM

DD

YYYY

What type(s) of therapy or service are you seeking? *

Individual Therapy

Couples Therapy

Family Therapy

Therapy for a Child/Teen

Group Therapy

Preferred Location(s)

Acworth

Telehealth (GA Residents)

No Preference

Preferred Availability *

Mornings (Before 12 pm)

Afternoons (12 pm - 4 pm)

Evenings (After 4 pm)

Please let us know if any of the following events or actions have occurred in the last 6 months:

Physical aggression to others

Substance abuse

Suicidal ideation/behaviors

Self-injury (non-suicidal, e.g., cutting, burning, etc.)

Hospitalization for psychiatric needs

Manic episode/Hallucinations

Consent + Privacy:

I agree to the terms of service and consent to the use of my information for scheduling and consultation communications.