Please be aware that this information is not currently handled via a secure server.  Your thoughtful answers here will help me figure out whether the clinical elements of this site have anything potentially useful to offer you. Be sure to read the considerations on the previous page if you have not already done so.

Your E-mail address-essential   (This should come automatically as you send your e-mail)

Your name, address and telephone number.

Age/Birthdate (I cannot serve minors without parental consent)

Are you employed part-time, full time, or going to school?

How much education have you completed?

Marital or partnership status.

Who lives in your household? Names, ages, relationship.

Why are you seeking help?

Past History of Psychotherapy or Psychiatric Treatment

Describe your past and present substance use

Do you have any significant medical problems? Describe

Are you taking any medications? List with dosages.

Describe any symptoms you may be having?  Examples are:  Depressed, sleep problems, problems with food, relationship problems, physical pain, panic attacks, lonely, fearful, confused, troubling thoughts, compulsive behaviors, hopelessness, helplessness, fearfulness, suicidal thoughts and feelings.

How long have you been experiencing these symptoms?

In the past, what have you tried to do to relieve these symptoms?
 
 

Your responses will help me plan your treatment.  Do not send payment information until you hear from me.

I will respond within 48 hours of receiving your intake. If you do not hear from me within this time frame it means it got lost in the email system, please send again.