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Contact
Intake form
Help us serve you better
Name
*
Email address
*
What is your preferred method of communication?
Please select at least one option.
Phone
Email
Text Message
What are your primary concerns or areas of focus for therapy?
Please select at least one option.
Anxiety
Depression
Sexual Health
Relationships
Trauma
Self-esteem
Stress Management
Life Transitions
Grief
Have you previously received therapy or counseling services?
Select
Yes
No
If yes, what type of therapy have you experienced?
Do you have any specific goals you would like to achieve through therapy?
How did you hear about rise to renew, PLLC?
Please select at least one option.
Referral
Online Search
Social Media
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What is your preferred session frequency?
Select
Weekly
Bi-weekly
Monthly
As needed
Do you have any medical conditions or medications that we should be aware of?
What is your age range?
Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 and older
Which service or services are you interested in?
Please select at least one option.
Individual therapy
Couples therapy
Poly-friendly therapy
Sex therapy
Additional questions or comments
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