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Welcome! We're so happy you found us :) If you're ready to take that first step, just fill out this form and we'll get started...

New Client Intake Form

First name*

Last name*

Email*

Phone*

Client's Date of Birth*

How would you like to be contacted?*

Phone

Text

Any of the above

I'm looking for....*

Help For Me and My Partner

Help For My Teen

Help for my Child/ Family Counseling

Just For Me

Medication Evaluation or Management

Psycho-social Educational Evaluation for My Child

Equine Assisted Psychotherapy

Information on Support Groups

Other

If you selected Support Groups, please let us know what topics you would be interested in:

I would like...*

In-person Only

Telehealth Only

I'm flexible

What qualities do you look for in a therapist? Choose as many as apply:

Someone who challenges me

Someone who gives good feedback

Someone who can teach me new skills

Someone who listens without interrupting

Someone with religious faith

Someone who is positive

Someone who is good at problem-solving

Someone with a sense of humor

Someone who provides structure

Someone who is open-minded

Someone with LGBTQ+ affiliation

Other:

Name of Insurance*

Member ID*

Days/Time You Are Available*

Country/Region*

Address*

City*

Zip / Postal code*

Check here if you have a secondary insurance.

Do you have a history within the last 6 months of suicide attempt?*

Yes

Are you currently in a household that is experiencing domestic violence?*

Yes

Tell Us a Little About You*

Please note: Key Therapy is not able to offer 24/7 crisis services. If you are in crisis, please call 211. If you are having a mental health emergency, call 911 or go to your nearest ER.

Keep me in the loop! I'd like to learn more about upcoming events and services.

Key Therapy Counseling

Call: 203-261-7090

or email:

contact.us@keytherapyllc.com

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