Intake Form

Please fill out the following intake form prior to your first session. Submissions 24 hours in advance are appreciated.


Please complete the form below

Name *
Birth Date *
Birth Date
Phone *
If referred by a client, who was it? If other, please explain.
1. Have you experienced any trauma in the past year? *
5. Sign up to receive inspiring updates and a complimentary e-book *
We respect your privacy