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Contact Us
Home
About Us
Our Therapists
Testimonials
FAQ
Blog
Press
Therapy Services
Individual
Couples / Family
Divorce Services
Online Video Therapy
Intake Forms
Individual
Couples
Family
Divorce Services
COVID-19 Resources
CDC Link
Mental Health Information Page (via CDC)
WHO Link
Kids Health – How to Talk to Your Child
Kids Health – How to Prepare Your Family
Contact Us
Family Therapy – Intake Form
If you have insurance questions,
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Name
*
First
Last
Email
*
Interested in virtual or in-person sessions?
*
Online therapy (also known as "Teletherapy")
In-person (when we are allowed to do so)
No preference
What can we help you accomplish?
*
Have you or family members sought therapy in the past? If so, anything negative or positive you experienced in that treatment?
*
Have you or family members ever had mental health emergencies in the past?
*
Crises such as: panic attacks, debilitating depression, suicidal feelings and/or attempts, any hospitalizations for mental health? If so, how long ago and what was the treatment for it?
Do your conflicts ever escalate beyond anything verbal?
*
What time would be best in your schedule to meet for therapy?
*
What would be the best style of communication for you?
*
When speaking with your therapist would a more direct/challenging approach be best or a collaborative/supportive approach?
Is there a specific therapist you would prefer to work with?
*
NO PREFERENCE
ANTONIA DI LEO
KEITH DIXON
SHIRA ETZION
MELISSA FULGIERI
ELISA GIZZO
QUINELLE HICKMAN
BREANA JOHNSON
TRACY CAVELL KEATS
KARA MCELANEY
How did you hear about us?
*
Is there anything else you would like us to know about you? Any other questions for us?
*