Intake form

Help us serve you better

Name *

Email address *

What is your age?

What is your gender?

What type of therapy are you interested in?

Please select at least one option.

Individual Therapy

Couples Therapy

Family Therapy

Group Therapy

Have you previously attended therapy?

What are your primary concerns or issues?

How did you hear about us?

What is your preferred method of therapy?

Do you have any specific goals for therapy?

Are you currently taking any medication?

If yes, please specify the medication(s) you are taking.

Which service or services are you interested in?

Please select at least one option.

Atendimento presencial

Atendimento on-line

Additional questions or comments

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