Name
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First Name
Last Name
Pronouns
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Please check as many as apply
Email
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Phone
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Which therapist are you interested in working with?
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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!
1. Available therapy appointments vary but include different slots M-F, with the first appt of the day beginning at 8:30am and the last appt beginning at 3pm. Will this work with everybody's schedules?
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*We may eventually have other openings but wanted to make you aware now so that you can determine best steps going forward. If you are not available on the days we currently have openings, you may check back or subscribe to our newsletter to be notified of any changes!
2. Do you have access to reliable wifi and/or a place to safely meet via telehealth?
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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.
3. Are you aware that we charge $200-300 per 60-80 min appt, depending upon size and needs of group/individuals seeking therapy?
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*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
4. Who is seeking therapy at this time, what are your names and pronouns, and what is your relationship to each other?
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*If seeking therapy with a partner or partners, what is your relationship structure? (ie: monogamous, open, non-hierarchical, etc)
5. What are your reasons for seeking therapy at this time? What are the goals you are hoping to work on together?
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6. Has someone in your lives recommended relationship therapy to you? If so, who and why?
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7. Is anybody involved currently participating in individual therapy? If so, who and what sorts of concerns are being worked on there?
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8. Has anybody done therapy in the past? If so, what did they like? What didn’t they like?
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9. Does anybody involved have any sort of mental health diagnoses that is significantly impacted by or significantly impacts the relationship dynamics? If so, what diagnoses and what support is in place or is needed?
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10. Is anyone taking any medications for mental health at this time? If so, what medications and how do they feel about them?
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11. Are there any concerns regarding substance use or abuse with anybody involved? If so, what steps have been/are being taken to address these concerns?
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Please note that we do not specialize in recovery. We are happy to support any work you may be doing but will refer you elsewhere if that is a primary reason you’re seeking therapy at this time.
12. Does anybody have any cultural or other identities that are important for us to know about? If so, please tell us more.
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13. Who or what do you consider to be supportive in your life at this time? Who or what do you consider to be supportive of your relationship?
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14. Please confirm having read and agreed to our policy regarding acute need below
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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.
15. Covid & Our Commitment to Public Health
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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.
16. Is there anything else you feel is important for us to know at this time?
You made it through all of our questions! Thank you. Somebody will be in touch with you in about 7 days!
If you were referred to us, who referred you? (If you were not referred and found us via one of the other ways listed above, simply write N/A)
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