Session Request

Strategy Session Request

Please help us to understand your needs better.

First Name

Last Name

Best phone number to reach you

Best time to reach you

What is the biggest change you would like to see in your life?

In what area of your life are you having struggles?

Are you seeing a therapist now?

If so, what prompted you to go to a therapist?

How long have you been seeing a therapist either currently or in the past?

Are you currently prescribed any medications?

If so, what and for how long?

Are you currently experiencing thoughts of suicide?

Have you previously made a suicidal gesture?

Are family and friends concerned about you and an addiction or abuse in any way?

Are you having trouble drinking more than you intended?

Are you noticing that you need more alcohol to obtain the desired affects?

Are you able to sleep 7-8 hours a night without interruption?

Are you mixing alcohol and other drugs, whether prescription or not?

Please check all that apply:

alcohol

drugs

prescription medications

gambling

food

sex

internet pornography

stealing

NOTE: Any information you share with us remains STRICTLY CONFIDENTIAL.

Thank you for your time. We will call you soon to schedule your strategy session.