Preferred Name

First name

Last name

Pronouns

Legal Name

As listed on insurance.

Legal First Name

Legal Last Name

Date of Birth

Email

Phone

Is it okay to leave a voicemail at this number?

Yes

No 2

Preferred communication method

Call me.

Email me.

How will you be paying for therapy?

Upload your Insurance Card - front & back

If you do not have your physical OHP card, please provide your OHP ID Number:

Are you covered by a secondary health plan? i.e. insurance through work, school, parents, etc.

I'm interested in working on:

Depression

Anxiety

Bipolar Disorder

Schizophrenia

Obsessive-compulsive disorder (OCD)

Post-traumatic stress disorder (PTSD)

Eating disorders (e.g. anorexia, bulimia, binge eating disorder)

Personality disorders

ADHD

Work-related stress or burnout

Life transitions (e.g., separation, retirement, becoming a parent)

Grief and loss

Chronic illness or pain management

Caregiver stress

Marital or couples conflicts

Family conflicts or dysfunction

Infidelity/ betrayal

Communication issues

Intimacy concerns

Low self-esteem

Body image issues

Identity concerns and exploration (e.g., LGBTQ+ identity exploration, racial or cultural identity)

Alcohol or drug abuse or addiction

Gambling addiction

Internet or gaming addiction

Childhood abuse or neglect

Domestic violence

Sexual assault or abuse

Witnessing traumatic events

Emotional eating

Body dysmorphia

Disordered eating patterns

Insomnia

Nightmares or night terrors

Sleep-wake disorders

Difficulty controlling anger

Aggressive behavior

Meaninglessness or purposelessness

Existential crises

Mortality concerns

Parent-child conflicts

Parenting challenges or concerns

Family planning or fertility issues

Career dissatisfaction or indecision

Workplace conflicts

Academic pressures or performance anxiety

Gender exploration or transition support

Gender affirming letters

Coming out shame with family

Discrimination or oppression

Acculturation or immigration stress

Societal pressures or expectations

Impulse control issues

Behavioral addictions (e.g., shopping, hoarding)

Sexual dysfunction

Intimacy concerns or avoidance

Asexual acceptance and exploration

Exploring needs/wants

Setting boundaries and standing up for yourself

Learning to say no with grace

Other (please describe in the summary box below)

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The follow questions are asked to ensure that Brave Ass Scaredy Cat Counseling can honor your level of care. Thank you taking the time to share intimate info.

Have you currently or recently had suicidal thoughts?

Have you currently or recently engaged in self harm? if yes, please share. (such as burning, scratching, cutting, hitting self).

Please share a brief summary of what brings you to therapy.

Have you been in therapy before?

Yes

No

Are you taking any medications at this time? This can be for medical or psychiatric reasons. If yes, we will follow up at your first session. I take a holistic approach to your treatment and coordinate with your current care providers as needed.

Yes

No

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What is your general availability for scheduling?

If Brave Ass Scaredy Cat has no availability at this time:

I'd like to be placed on their waitlist.

I'll keep searching for a therapist elsewhere.

How did you hear about Brave Ass Scaredy Cat?

Telehealth (video calls) therapy sessions are limited. In-person sessions are Brave Ass Scaredy Cat Counseling's primary availability at this time.

I'm down for in-person.

I only want to meet via telehealth.

Any questions or anything else I should know?

Individual Therapy

Preferred Name

Legal Name

_____________________________________________________

The follow questions are asked to ensure that Brave Ass Scaredy Cat Counseling can honor your level of care. Thank you taking the time to share intimate info.

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