Chart Your Course

You’re about to take the first step in a series of actions toward making a course correction in your life. It’s often said that the journey of a thousand miles begins with the first step—but in reality, it first begins with a clear understanding of both where you want to go and where you currently are. Once those two points are identified, then the fist step can be taken.

The form below is your starting point and will help clarify your goals moving forward. Thank you for taking the time to invest in yourself. I’m excited for what comes next.

PLEASE NOTE
I am only licensed to practice within the state of Florida.
You must be physically present and reside in the state of Florida to be seen.

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Name *

First

Last

Email *

Phone *

What do you think you want to address in therapy? *

What has caused you to seek help at this time? *

How long have you been in need of help? *Few WeeksFew MonthsMaybe a YearMore Than a Year

Have you had previous therapy or help in the past? *

• Yes - Therapy was very helpful
• Yes - Therapy was kinda helpful
• Yes - Therapy wans't really helpful
• Yes - Waste of time
• Yes - Not therapy, just friends/family/self-help
• Other

If you had therapy in the past, what did you like and/or dislike about the experience? What did you find most helpful and least helpful?

What do you hope to feel or experience differently by the end of our work together? If you don't know, its okay.

How often have you been bothered by your particular problem?

Selected Value: 0

When you are bothered by your problem, how long does it typically last?

Selected Value: 0

you okay. check

How would you rate the level of intensity/impact on your daily functioning?

Selected Value: 0

How important is it for you to begin the work to make the changes you're considering?

Selected Value: 0

How motivated are you to make changes in your life right now?

Selected Value: 0

How confident are you in your ability to make the changes you're considering?

Selected Value: 0

How ready are you to take action toward achieving your goals?

Selected Value: 0

Please check any that have been true for you in the last 12 Months *

• Taking prescribed medications (for mental health)
• Prescribed medication for mental health, but don't really use them
• Had thoughts of ending your life or harming yourself in some way
• Had a plan of how you would end your life or how you would harm yourself
• I have thought about acting on my plan

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