Just Right Therapy | SimplePractice

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Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What symptoms or situations would you like help with?

Anxiety Attentional difficulties or ADHD Behavioral issues Depression Relationship issues Substance use Trauma OCD Body focused repetitive behaviors (hair pulling, skin picking) Autism other neurodivergence challenges with eating other

Please check any that apply about your treatment history

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past None of these apply

Administrative

How did you hear about Just Right Therapy

Enter here who referred you or how you found the practice

Client Preferences

Is there anything specific you'd like me to know before we speak?

For example: what you'd like to focus on, any access needs, general reason not covered by check boxes

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

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.