A short form.

Six fields, and a line or two about what brings you. Once I have this, I’ll open a secure client portal for you and send through a fuller intake to complete there — in a system built to hold this kind of detail safely. Nothing here commits you to anything.

Where I can work with you. Psychotherapy is a regulated activity, and I provide it to people located in New York State or Québec. Coaching and consultation are available wherever you are. Some jurisdictions outside North America don’t reserve psychotherapy to locally licensed practitioners; if you are elsewhere, please say so below and I’ll look into it properly rather than guess.

I · You

Full legal name

Date of birth

Phone

Home address

Where you’ll be during sessions (if different)

II · What you’re asking about

Enquiring about

Briefly, what brings you here?

A few lines is plenty. There is room for the fuller story later, in the portal.

How did you come to find me? (optional)

You’ll hear from me directly. If you are in crisis, please don’t wait on this form — call or text 9-8-8 (US & Canada), 1-866-APPELLE in Québec, or 911.