Let’s Chart My Course!

You’re about to take the first step in a series of actions that can lead to meaningful course correction in your life. It’s often said that the journey of a thousand miles begins with a single step. But in reality, the journey begins even before that—with a clear understanding of where you want to go and an honest assessment of where you are right now. Once you have identified both points, you can determine the direction you need to take and confidently begin that first step.

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 *

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Email *

Phone *

What would you like 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

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 want to be your criteria for success? What does a successful therapy outcome for you look like?

How often have you been bothered by your particular problem?

Selected Value: 0

The Lower the number, the less bothered you have been. The Higher the number, the more bothered you have been.

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

Selected Value: 0

The Lower the number, the shorter it lasts. The Higher the number, the longer is lasts.

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

Selected Value: 0

The Lower the number, the less intense/impact on your daily functioning. The Higher the number, the more intense/impact on your daily functioning.

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

Selected Value: 0

The Lower the number, the less important. The Higher the number, the more important.

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

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The Lower the number, the less motivated you are to make changes. The Higher the number, the more motivated you are to make changes.

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

Selected Value: 0

The Lower the number, the less confident you are. The Higher the number, the more confident you are.

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

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The Lower the number, the less ready you are to take action NOW. The Higher the number, the more ready you are to take action NOW.

For a toward

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

• Taking prescribed medications (for mental health)
• I am or have been prescribed medication for mental health, but don't really use them
• I have experienced thoughts of harming myself, but they come and go
• I have experienced thoughts of harming myself, and they haven't gone away
• I have had a plan of how I would end my life or how I would harm myself

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Completing this form does not create a therapist-client relationship or guarantee an appointment. It helps me learn a little about what you are looking for and determine whether my services may be a good fit.