NEW CLIENT QUESTIONNAIRE

Hi! The answers you share on this form will help me better understand what you’re looking for in therapy right now, and whether I’m the right fit to support you.

Name

First Name

Last Name

Email

Phone Number

Date of birth

Where do you live? City, state?

What is bringing you to therapy at this time? What are you hoping to address in sessions?

What are your goals for therapy? Please list three things you are needing at this time.

Do you have health insurance and if so, which one?

What else would you like me to know? Do you have any questions for me?

NEW CLIENT QUESTIONNAIRE

Wildflower Wellness Collective Inc.