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Name (first and last name) *
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Name of insurance/type of insurance * PPO, HMO etc…
How did you hear about me? * —以下から選択してください—Google adInstagramTwitterFacebookSearch engineOther
Please specify where you heard about me. * If doctor or any other medical provider referred you, please provide the name of the provider.
Concerns * —以下から選択してください—Adult child of toxic parentsDepressionAnxiety/WorryAdolescentsAutistic adultSports injury
Please check the boxes of the symptoms you have been suffering from. * Feeling depressedlost interest or pleasure in activities that I usually enjoylack of appetite or increased appetiteDifficulty sleeping, sleeping too much, waking up in the middle of the nightfeeling irritabletake more time to finish tasksDifficulty finding self-worthfeel guilty easilydifficulty concentratingdifficulty making decisionsThink about death oftenfeel like I want to escape from the current situationengage in self-harm behaviorthink about suicide
Please check the boxes of the symptoms you have been suffering from. * Think about what makes me worried/anxious oftenDifficulty stopping thoughts that make me worried/anxiousFeel tense/nervous most of the timeBeing easily tiredDifficulty concentratingDifficulty organizing thoughtsFeeling irritatedMuscle aches (such as neck, back, and shoulders) are more severe than usualExperiences headaches and/or stomachaches without knowing what exactly caused themDifficulty sleeping, sleeping too much, waking up in the middle of the night
What prompted you to believe you need therapy as an adult child of toxic parents? *
What prompted you to believe you need therapy for your child? *
What prompted you to believe you need therapy as an autistic adult? *
What prompted you to believe you need therapy as a sports injury? *
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