Intake Form

Intake Form

If you are a resident of Massachusetts or Vermont and are interested in seeing me for therapy, please complete my online intake form.

First name

Last name

I’ve experienced suicidality in the last year.

Yes

I’ve needed partial or inpatient hospitalization in the last year.

Yes

What has helped specifically? (Self help books, therapy, holistic, 12-step)

What are some things you’d like to heal and or change?

What led you to this moment in seeking change. (break up, saw a video, something keeps prompting you?)

Thank you for taking the time to complete and submit this form. I'm the only person who will see your form. Therapy depends on a good fit between the client and the therapy offered. If I determine from your responses that you could be a good fit for the therapy I offer, I will reach out to you to schedule a video consultation at no cost. I try to reach out within a week. If you don't hear from me, it means I don't think the therapy I offer would be a good fit for you.

Christopher Wellness LLC Healing Childhood Trauma

Intake form

Christopher Wellness LLC
Healing Childhood Trauma