Primary Partner's First Name
*
Secondary Partner's First Name
*
Primary Partner's Last Name
*
Secondary Partner's Last Name
*
Primary Partner Email Address
*
Secondary Partner's Email Address
Primary Partner Phone Number
*
Secondary Partner Phone Number
Primary Partner Gender Identity
Female
Male
Trans Female
Trans Male
Nonbinary
Other
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Secondary Partner Gender Identity
Female
Male
Trans Female
Trans Male
Nonbinary
Other
Choose Not To Disclose
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Primary Partner Pronouns
Secondary Partner Pronouns
Primary Partner Date of Birth
Secondary Partner Date of Birth
Fees + Third Party Payors
*
Self Pay/OON
Lyra
Veteran (VA)
Allied Trades
Teamsters
Other
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Note: We are a private pay practice and do not accept in-network insurance coverage.
What is your preferred contact method?
Phone
Email
Text
All of the Above
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Please select your primary reason for seeking therapy:
*
Depression
Anxiety/Panic
Relationship Issues
Substance Use Problems
Suicidal Thinking/Self Harm
Trauma
Grief/Loss
Stress or Burnout
LGBTQIA+ Support
Neurodivergent Support + Diagnosis
OCD
Body Image
Eating Disorders
Behavioral
Adjustment/Transition Difficulty
Academic/Work Difficulties
Family Conflict
Communication Skills
Phobias
ART
DBT-Full
DBT-Group Only
ADHD + Autism Testing/Evaluation
Other
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Select additional reasons for seeking therapy below (check all that apply)
Depression
Anxiety/Panic
Relationship Issues
Substance Use Problems
Suicidal Thinking/Self Harm
Trauma
Grief/Loss
Stress or Burnout
LGBTQIA+ Support
Neurodivergent Support + Diagnosis
OCD
Body Image
Eating Disorders
Behavioral
Adjustment/Transition Difficulty
Academic/Work Difficulties
Family Conflict
Communication Skills
Phobias
ART
DBT-Full
DBT-Group Only
ADHD + Autism Testing/Evaluation
Other
Which quality is most important to you in a therapist?
Gender
Lived Experience
Years in practice
Cost
DBT-LBC Certified
Specialized Training
BIPOC Identified
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How did you hear about us?
*
Google Search
Word of Mouth
A Current Client
Provider Referral
I'm A Returning Client
Social Media
Instagram
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If other, please specify:
Preferred Location
*
Voorhees, NJ
Moorestown, NJ
Online
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Preferred Appt Time
*
Mornings 9-12
Afternoon 12-4
Evenings 4-9
Other
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Preferred Appointment Days
*
Monday
Tuesday
Wednesday
Thursday
Friday
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