Forms | HTCW

Intake Form

Please complete brief intake from below. Please note this information will be kept confidential under ethical practices.

Full Name

Phone

Birthday required

Subject

Message

What service are you interested in? Required

Individual Therapy

Clinical Supervision

Wellness Group

Are you currently receiving services from a mental health therapist, life coach, psychiatrist, or psychologist?

Yes

If you are not currently receiving mental health services, but have received mental health services in the past, please provide last date of service and type of provider seen.

I confirm that I am aware that Clinical Supervision and Wellness Group services provided by Healthy Transitions Counseling & Wellness, LLC are self pay at this time, and that payments are required at the time of scheduling any services. I am aware that all payments are non-refundable. I agree to the terms and conditions.

Thanks for submitting!