Name *

First Name

Last Name

Pronouns *

Please check as many as apply

They/them

She/her

He/his

Other (please describe in last question/comments below)

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which therapist are you interested in working with? *

Em works with relationships of many sorts, with a focus on romantic relationships. Jenny works with families, with a specialization in helping parents and teens better understand each other. *Please feel free to elaborate further in the comments section at the end of this form!

Em

Jenny

Whoever is available

1. Available therapy appointments vary but include different slots Monday-Friday, with the first appt of the day beginning at 8:30am and the last appt beginning at 4pm. Will this work with everybody's schedules? *

Yes

No

2. Do you have access to reliable wifi and/or a place to safely meet via telehealth? *

All appointments are via telehealth at this time. We will provide you with a link to your appointment, so you do not have to be highly tech savvy but do need to have reliable wifi and a safe/private place to meet.

Yes

No

3. Are you aware that we charge $200-300 per 60-80 min appt? *

*Please note that we reserve a limited number of sliding scale spots. If this is something you would like to explore further, please indicate this in the comments section at the end of this form

Yes

No

14. Please confirm having read and agreed to our policy regarding acute need below *

If anybody is currently having serious thoughts of ending their life or has had serious suicidal thoughts or made attempts in the last 6 months, we are not able to begin a therapeutic relationship at this time. Our belief is that acute needs are best addressed by services able to provide more support and wrap-around care than is available through a small private practice. If you are in need of urgent care, please refer to the information provided at the top of this form or refer to our webpage for other referrals for wrap-around care.

I read and agree to North Coast Connection's Acute Needs Policy

15. Covid & Our Commitment to Public Health *

As public health is a core value of North Coast Connection, we take a firm stance regarding Covid safety and believe in taking necessary steps toward protecting ALL community members. For the time being, all appointments will be conducted via telehealth. When it is safer to return to in-person services, we will continue to utilize different risk-mitigation efforts to keep doing our part in keeping all community members as safe as we can. We will additionally continue to offer telehealth appointments to assure that mental health support continues to be accessible to all of our clients. We appreciate your understanding.

We have read and understand North Coast Connection's Covid policies