Full Name *

Teen Girl's Name (if necessary)

Teen Girl's Age (if necessary)

Relationship to Teen (if necessary)

Whom Are You Seeking Counseling For? *

Partner's Full Name

Partner's Phone Number

Partner's Email Address

How would you like to receive services? *

In-person only

Telehealth only

Open for both

Please provide a few times you are available for counseling *

Would you like first availability or work with a specific clinician? *

What is the best way to contact you? *

Phone

Email

Text Message

Briefly describe the issue you would like to work on. *

STOP --> Review our Out-of-Network/Private Pay policy?

Have you reviewed our OUT-OF-NETWORK/PRIVATE PAY policy? *

Yes

No

How did you hear about us? *

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Seven Oaks Mental Wellness Therapy therapists and/or office staff communicating with me via email or text message