Therapy Collaborative LCSW PLLC, dba The Therapy Collective

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Some of our clinicians are bilingual. If you would like to have therapy in another language, list it here. (OPTIONAL)

Reason for care

What is the reason for seeking care?

Limited to 600 characters

We are eager to get to know you better. Please share context relevant to your history and current concerns. Click as many as apply.

I have been seen by a therapist before. I currently take medication for symptoms related to anxiety, depression or another mental health issue. I have concerns about my drug or alcohol use. I do experience thoughts and urges to hurt myself and or suicidal ideation. I understand these questions are important and prefer to explore them with a clinician.

What type of services are you interested in - individual, relationship (couples) or group therapy?

Individual Therapy Relationship Therapy (Couples) Group Therapy - Adult Adoptees Group Therapy - Waitlist (fill in your interest below)

If you selected a waitlist group therapy option, please indicate which group interests you.

Billing & Payment

Payment method

How do you plan to pay for your therapy?

If you would like to use insurance, we can help you check your benefits and estimate your costs. To expedite this process, please share insurance information and upload your insurance card. (OPTIONAL)

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Therapist Selection Options

Please indicate below if you have a therapist in mind that you would like to work with or if you would like our help in matching you.

I have a therapist in mind. (Please select their name from the drop down box below.) I need support in identifying a good therapist match and will complete the section below so that the reception team can better understand my needs/preferences. (Please skip selecting a clinician and move on to the next question.)

Preferred clinician

Select a clinician from the list

I am open to exploring a good therapist match. Here is information that might help the practice identify a good fit.

Feel free to include information here about a preference in therapist related to experience, approach or identity. Clients might reference here, among other things, gender, religion, special skills, age, race, lived life experience, sexual orientation, etc...

Limited to 600 characters

How else can we help? (OPTIONAL)

Tell us here if there is anything specific you need to know, would like to explore or want to discuss with our reception team. (This could include, for instance, exploring our fees, insurance coverage, sliding scales/special low cost programming or any other informational needs you may have.

Limited to 600 characters

Preferred appointment times - choose all times that would work for you (OPTIONAL)

Morning Afternoon Evening Weekend I am flexible and can meet whenever.

By checking this box you agree that we can contact you by the email address or telephone that you have included in order to support you in finding a therapist and beginning treatment at our practice.

I agree.

By checking this box you indicate that you have read our Terms of Use (https://therapy-collective.com/terms-and-conditions)and Notice of Privacy Practice (https://therapy-collective.com/privacy-policy) for this interactive website.

I have read both and agree.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.