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What are you hoping to find support with in therapy? (Check all that apply)

Anxiety or chronic worry Relationships or dating Self-esteem or identity Substance use Stress or life transitions ADHD/attention/executive functioning Other

Please explain in more detail what you are seeking support with.

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Have you experienced or received support for any of the following? (Check all that apply)

Currently in therapy In therapy in the past Currently taking psychiatric medication (including antidepressants, stimulants, etc.) Taken psychiatric medication in the past Hospitalized for mental health reasons currently or recently (in the last 12 months) Hospitalized for mental health reasons previously (longer than 1 year ago) Diagnosed neurological or psychiatric disorder Attempted suicide in the past None of the above

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