About you

We'll start with the basics — how to reach you.

Full name *

Email *

Phone *

Best way to contact you *

EmailPhoneText

Are you requesting therapy for…? *

MyselfSomeone else

What you're working on

Select as many as feel right. "Not sure yet" is a real answer.

Other (optional)

Logistics

How and when can we meet?

Preferred format *

In-person (Spring Hill)TelehealthEither

Preferred days & times

Weekday AMWeekday PMEveningsWeekends

Preferred therapist

Will you be applying for sliding-scale pricing? *

YesNoTell me more

Anything else & consent

Last step. Thank you for making it here.

Anything else you would like our team to know?

Confidentiality limits (read before consent)

Your therapist will hold what you share in confidence with these legal exceptions: (1) mandated reporting of abuse or neglect of a child, elderly, or dependent adult; (2) serious risk of harm to self or others; (3) a court order.

Email and SMS are not fully encrypted channels. By choosing email or text as your preferred contact, you accept the minor risk that someone other than you could view those messages.

I consentI understand that by submitting this form I'm giving Wholehearted Counseling permission to contact me via phone, email, or text to schedule. I've read and accept the confidentiality limits above.

Taking the first step is the hardest part. We'll make it simple.

About you

What you're working on

Logistics

Anything else & consent