Therapy Booking Form

Therapy Booking Form

Please fill out the form below to schedule your therapy session.

Name

    Phone number

      Email

        Appointment Date

          Appointment Time

          Therapy Type

            • Cognitive Behavioral Therapy (CBT)

            • Psychodynamic Therapy

            • Family Therapy

            • Couples Therapy

            • Trauma Therapy

            • Grief Therapy

            • Art Therapy

            Session Format

              • In-Person

              • Virtual Meeting

              • Phone Consultation

              Select Duration

                • 30 Minutes

                • 45 Minutes

                • 60 Minutes

                • 90 Minutes

                Are you taking any medications?

                Do you have any diagnosed mental health conditions?

                Do you have any physical conditions or disabilities that we should be aware of?

                Emergency Contact Information

                Name

                  Phone number

                    Relationship

                    Cancellation Policy

                    Please note that cancellations or rescheduling must be made at least 24 hours in advance. Failure to cancel within this time frame may result in a cancellation fee.

                    Client Consent

                    By signing below, I acknowledge that all information provided is accurate and I consent to participating in therapy sessions based on the details provided.

                    Name:

                    Date:

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                    Thank you for booking with us!

                    We look forward to serving you.

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