Quick Get to Know You

Everything you discuss on this form, or in the future with a Whole Connection therapist, will be kept confidential and stored only in our locked locations. Your privacy is important to us, but we are also trying to make sure that our services are a good fit for you.

Therapy itself will feel a bit different than the first contact which is a history gathering appointment.

 

Please complete the form below

Name *
Name
Please Supply Month/Day/Year we use this to make sure you are in network with us
This will help us make sure we identify you correctly. ex) She/Her/Hers, they/them/theirs
Can we leave you a voicemail, text, or email message on this number and email address? *
Our full rate is $125/hr, we try to a accommodate people with much lower rates. We ask you to let us know now or over the phone what you feel you are able to afford in a month and we will do our best job to work with it. Please know we try to accommodate for many people and will do our best to help if we are able.
If yes, please explain
If so please describe what that looked like and how it looks currently
If so when and did you have follow up treatment of any kind?
What are the current medications and the dosage you are taking
How was that experience?
(brief description)
We currently are located on the second floor, but do have an office we can use on the 1st floor if needed
This could be a recent event or something about you that you want us to know like preferences in therapists or how you might identify
Are you interested in Group Therapy
If yes, which group? Group listings are on our Current Groups Page
Currently we do not accept Medicare