Name *

First Name

Last Name

Phone

(###)

###

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Client's Date of Birth *

MM

DD

YYYY

If you selected "Therapy" please check all that apply:

General Wellness

Anxiety

Depression (including Post-Partum)

Autism/ADHD

Life Changes

Grief/Loss (including Job loss)

Stress (Work, Life, Financial, School/Bullying, Caregiver burnout)

Trauma/PTSD

First Responder

Substance Abuse/Addiction

Couples (Infidelity, Divorce, Relationship Stress)

Family (Relationship Stress, Blended Family)

Abuse/Assault (Domestic abuse, Rape, Intimate Partner Violence)

Eating disorder(s)/Body Image/Dysmorphia

Sexuality/Gender Identity

Suicidal Ideation/Self Harm/Cutting

Religious Coercion

Other (please indicate in your message)

Do you have any family members who are currently engaged in therapy at CORE? *

Yes

No