Intake form

Name *

Email address *

What is your age?

What is your gender?

What is your primary reason for seeking therapy?

Please select at least one option.

Anxiety

Depression

Stress management

Relationship issues

Trauma

Self-improvement

Have you previously attended therapy?

If yes, what type of therapy did you receive?

Please select at least one option.

Cognitive Behavioral Therapy

Dialectical Behavior Therapy

Psychodynamic Therapy

Humanistic Therapy

Do you have any medical conditions that may affect your therapy?

Are you currently taking any medication?

If yes, please list your medications.

What are your goals for therapy?

How did you hear about us?

Please select at least one option.

Friend

Family

Social media

Website

Which service or services are you interested in?

Please select at least one option.

Acompañamiento psicológico

Terapia psicologica con enfoque en psicoterapia y neurociencia

Ecoterapia en Toronto, Canada

Additional questions or comments

Neuroheal