Begin Healing Today! Name * First Name Last Name Phone * (###) ### #### Email * Clarifying Questions 1. What the Presenting Problem(s) 2. Scale of 1-10, rate the current level of stress or distress due to Problem(s)? Are you willing to be placed on a waiting list for your preferred counselor? Yes No Would you be open to working with one of our in-office colleagues if they are available sooner? Yes No Thank you for taking the time to complete this form. Your responses will greatly assist us in tailoring our approach to meet your unique needs. We will be in touch soon to discuss the next steps of a consultation or begin session. If you have any immediate questions or concerns, please feel free to reach out via call/text to 720-257-9263 Schedule your Initial Session to Get the Support that you Need.john@known.care(720) 257-9263
