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Menu
Home
Who We Are
About Us
Our Partners
What We Do
What You Can Do
Resources
Q Convos Podcast
Resources & Reports
Violation Report Form
Services
Mental Health Therapy
Book A Doctor’s Appointment
Emergency Fund
Self-Test Kit Eligibility Form
News
Blog
Recent News
Contact Us
Menu
Home
Who We Are
About Us
Our Partners
What We Do
What You Can Do
Resources
Q Convos Podcast
Resources & Reports
Violation Report Form
Services
Mental Health Therapy
Book A Doctor’s Appointment
Emergency Fund
Self-Test Kit Eligibility Form
News
Blog
Recent News
Contact Us
Therapy
Client Intake Therapy Form
Please enable JavaScript in your browser to complete this form.
Applicant Details
All information you provide here is strictly confidential in accordance with the policy and ethical procedures of our organization. Be rest assured that you are always safe with us. This data takes less than 10 minutes to complete.
Full Name
*
First
Last
Email
*
Whatsapp Phone
*
Employment Status
*
Employed
Self-Employed
Unemployed
Age
*
What is your sexual orientation? (pick only ONE)
*
Gay
Lesbian
Bisexual
Straight
Pansexual
Asexual
Queer
What is your gender identity? (pick only ONE)
*
Transgender Man (you were born female, but identify as male)
Transgender Woman (you were born male, but identify as female)
Cisgender Man (If you were born male, and still identify as male)
Cisgender Woman (you were born female, and still identify as female)
Gender Non-Binary (You do not identify as strictly a man or a woman)
Intersex (you were born with sexual or reproductive anatomy that doesn't seem to fit the typical definitions of female or male)
In the last 3 months, have you had or currently experiencing any significant life changes/stressor?
*
Frequently
Sometimes
Rarely
Never
How often do you experience any of the following? Tick all that apply to you.
Tick all that apply to you.
How often do you experience any of the following? Tick all that apply to you.
*
Frequently
Sometimes
Rarely
Never
Loss of interest in pleasurable activities
*
Frequently
Sometimes
Rarely
Never
Consistently depressed or down nearly everyday
*
Frequently
Sometimes
Rarely
Never
Think that you would be better off dead or wish you were dead
*
Frequently
Sometimes
Rarely
Never
Engage in any recreational drug use (such as alcohol, cigarrete, stimulants, cannabis, tramadol, codeine, cocaine, tobacco etc.)?
*
Frequently
Sometimes
Rarely
Never
Actual or threaten death, sexual violence or serious injury in the past
*
Frequently
Sometimes
Rarely
Never
Intense need to do away with your gender features and the desire to have the features of the other gender
*
Frequently
Sometimes
Rarely
Never
Feel unworthy of love, respect, and incompetent about who you are and what you can do
*
Frequently
Sometimes
Rarely
Never
How often do you experience any of the following?
Tick all that apply to you.
Extreme mood swings/fluctuation
*
Yes
No
Extreme anxiety
*
Yes
No
Phobia
*
Yes
No
Sleep disturbance
*
Yes
No
Panic attack
*
Yes
No
Hallucination
*
Yes
No
Eating disorder
*
Yes
No
Repetitive thoughts (e.g., Obsession)
*
Yes
No
Tell your therapist how you are feeling right now (Optional).
Submit
