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Head 2 Heart Psychology
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Intake form
Help us serve you better
Name
*
Email address
*
What is your preferred method of contact?
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Phone
Email
In-person
What type of therapy are you seeking?
Please select at least one option.
Individual therapy
Couples therapy
Family therapy
Online counseling
What are your primary concerns or issues you're facing?
Do you have any previous experience with therapy?
Select
Yes
No
If yes, please describe your previous therapy experience.
What are your goals for therapy?
How did you hear about head 2 heart psychology?
Select
Referral
Social Media
Website
What is your availability for appointments?
Please select at least one option.
Weekdays
Weekends
Evenings
Mornings
Do you have any specific preferences for your therapist?
Are there any medical conditions or medications we should be aware of?
Which service or services are you interested in?
Please select at least one option.
Individual therapy
Couples therapy
Online counseling
Service title 7
Service title 8
Additional questions or comments
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