Credit Card Authorization
Insurance Verification Request
New Client Intake
Psychotherapy Registration Packet
Sample Page
Staff Dashboard
Staff Login

New Client Intake

Welcome. This short intake helps us understand what you are carrying and match you with the right therapist. Everything you write is private and goes only to our care team.

Your details

Full name *

Phone

About you

Date of birth *

Pronouns

Address (city, state, ZIP) *

We must confirm the state you are located in.

What brings you here

In your own words, what would you like support with? *

Take as much space as you need.

Which kind of support are you looking for? *

Individual therapy Couples / relationship therapy Not sure yet

What have you experienced recently?

Select all that apply.

Anxiety Depressed mood Grief or loss Relationship difficulty Trauma Sleep problems Work or life stress

Have you been in therapy before?

Yes, currently Yes, in the past No

Safety

Are you currently having thoughts of harming yourself or others? *

If you are in immediate danger, please call 911 or 988.

No Yes Prefer to discuss in session

Practical details

Preferred session time

How did you hear about Rumi's Den?

Consent

I consent to a telehealth or in-person consultation and understand this form is not therapy. *

I consent

Type your full name as your electronic signature *

Typing your name acts as your electronic signature.

Your answers are sent privately to your care team.

My Blog

My WordPress Blog

Blog
About
FAQs
Authors

Events
Shop
Patterns
Themes

Twenty Twenty-Five

Designed with WordPress