Name

First Name

Last Name

Have you experienced significant emotional distress or upheaval that affects your day-to-day functioning?

Yes

No

Maybe

Are you open to exploring and addressing your family history's potential influence on your current struggles or challenges?

Yes

No

Maybe

Do you feel motivated and prepared to actively engage in therapy sessions to address past experiences and patterns?

Yes

No

Maybe

Are you seeking long-term healing and growth rather than just short-term solutions to your current challenges?

Yes

No

Maybe

Are you in the state of Texas and over the age of 18?

Yes

No

Are you looking for a therapist that is in-network with your insurance, or are you open to out of network care?

In Network necessary

Out of Network is a possibility

I do not want to use insurance

Have you been to therapy before but are looking to go deeper?

Yes

No

Maybe

If you are looking for in-person therapy in the League City, TX area, are you comfortable with dogs?

Yes

No

Maybe

Are the symptoms you're experiencing manageable with non-crisis therapy once a week, or do you need a higher level of care?

Manageable with help

I need a higher level of care

I'm not sure