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Are you completing this form for yourself or on behalf of someone else?

If you’re completing this form for someone else, what is your name and relationship to them?

If you are completing this on another person's behalf, please answer the remaining questions about the person seeking therapy unless otherwise noted.

Will you be able to be physically located in Washington, DC, or Maryland during every session?

Your physical location during the appointment matters, even if your home address is elsewhere.

Yes No

Are you comfortable attending therapy by video?

All appointments are virtual through the Simple Practice Telehealth platform.

Yes I’m open to it, but I have questions No, I need in-person appointments

Will you have access to a private space, reliable internet, and a device with a camera and microphone for sessions?

Yes I may need help figuring out a workable setup No

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.