Your name *

Add the name of the person filling out the Intake (Your name)

First Name

Last Name

Relationship to the New Client *

Please describe your relationship to the new client.

Self

Parent

Guardian

Extended Family

Other

New Client Name *

Please share the name of the person you want to schedule an appointment for

First Name

Last Name

History with Therapy *

Do you have previous experience with therapy? Please share...

Yes. I have attended therapy within the last 2 years

Yes. However, it has been more than 2 years since I attended.

No. I have never attended therapy.

Type of Therapy *

What type of therapy are you seeking? List all that apply

Individual

Couple

Parenting

Family

Group

Appointment time? *

What time do you prefer to have appointments? Check all that apply

Morning, 8 am - 11 am

Midday, 12 noon - 1 pm

Afternoon, 2 pm - 5 pm

*Evening, After 5pm (*Currently, evening sessions are not available.)

Appointment type *

Do you prefer in-person or virtual sessions?

Virtual Only

In-person Only

No preference, Either Virtual or In-person is fine

Phone *

Please share the phone number where you prefer to be contacted?

(###)

###

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***Please check and acknowledge *

I acknowledge that Myqueology is a self-pay practice and does not take insurance. Full payment will be due at the time of service. A SuperBill is available upon request for clients to file for out-of-network reimbursement with their insurance carrier.