Intake form

Help us serve you better

Name *

Email address *

What is your preferred method of contact?

What is your age range?

What are your primary reasons for seeking therapy?

Please select at least one option.

Anxiety

Depression

Stress management

Relationship issues

Trauma

Self-esteem

Work-related issues

Seeking Diagnosis

Other

Have you previously received therapy?

If yes, please specify the type of therapy received.

Do you have any specific goals for therapy?

Are you currently taking any medication for mental health issues?

If yes, please list the medications.

Do you have any medical conditions that we should be aware of?

How did you hear about elevate health center?

Additional questions or comments

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