New Therapy Client Intake Form

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New APRN Appointment Request

Office Hours 10am-4pm M-Th
Therapy Hours: 7am-8pm M-F & Weekends By Appointment

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New Therapy Appointment Request

New APRN Appointment Request

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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

First name*

Last name*

Email*

Phone*

Client's Date of Birth*

Month

Day

Year

How would you prefer to be contacted?*

Phone

Text

Any of the above

I am looking for...*

A therapist just for me

Couple's therapy

Therapy for one or more of my children

Equine therapy

Groups

Other

I prefer to meet*

In person

Online

I'm flexible

Qualities I look for in a therapist include...

A sense of humor

Someone who listens without interrupting

Someone who challenges me

Someone who is good at problem-solving

Someone who provides structure

Someone who gives good feedback

Someone involved in the LGBTQ+ community

Someone who has a positive outlook

Someone who is nurturing

How did you hear about us?*

I am a returning client

Someone who is a current Key Therapy client

Google

A family member or friend

Someone from my child's school

Facebook or other social media

Psychology Today

My insurance company

My doctor, APRN, or other healthcare provider

Other

If you were referred by your PCP, what is their name?

Name of Insurance (if none, please write N/A)*

Member ID (if none, please write N/A):*

Group RX Number (if none, please write N/A):*

Days/times you are available:*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Are you a veteran or an active member of the military?:*

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

Are you currently involved in any legal disputes?:*

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

If you are seeking services for your child, please describe the marital and custody status of the child's parents. Is DCF involved?:*

Tell us a little about you, and your situation to help us match you with the right person:

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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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

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