Intake form

Name *

Email address *

What is your age?

What mental health challenges are you experiencing?

Please select at least one option.

Generalized Anxiety

Social Anxiety

OCD

Depression

ADHD

Schizophrenia

Bipolar Disorder

Psychosis

Other Mood Disorders

Have you previously sought therapy or mental health services?

If yes, please specify the type of services received.

What is your preferred method of communication?

Please select at least one option.

Phone

Email

In-person

Video Conference

Do you have any specific goals for therapy?

Do you have any medical conditions we should be aware of?

Are you currently taking any medication?

If yes, please list the medications you are taking.

What is your current employment status?

How did you hear about us?

Please select at least one option.

Referral

Search Engine

Social Media

Which service or services are you interested in?

Please select at least one option.

Individual therapy

Family counseling

Anxiety and depression treatment

Consultation

Bipolar disorder screening and treatment

ADHD

Additional questions or comments

K.C Cares for the Mind LLC