Christian Talk Therapy

HEAL. TRANSFORM. BE FREE.

Sophia Avery, MA

Christian Therapist

Christian Talk Therapy
Available Worldwide
via Text Messaging or Email

ph: 470-223-2276
savery@christiantalktherapy.com

INITIAL INTAKE FORM

Counseling Disclosure Statement

Before engaging in therapy, we require that you read and accept our Counseling Disclosure Statement.

Click Here to review the form and once you have read it, please type "Yes" at the first area on the right. If you have questions, please send an e-mail from the "Contact Us" page.

Suicide/Homicide Alert

If you are having thoughts of hurting yourself or someone else, for your safety, do not call us.

Please immediately go to the nearest hospital Emergency Room or dial 9-1-1 for help and/or call the Suicide Hotline at 1-800-273-8255

Please Complete each item below:

*If you have read and accept the Counseling Disclosure Statement, please type "Yes" below.

*First Name:

*Last Name:

Age (or age of client):

*Email:

*Contact Number:

Please provide the best number to reach you.

Contact Preference:

City:

*State:

*Country:

Type of Service Requested:

Please indicate the type of Counseling you are seeking--Individual, Marriage, or Relationship or Pre-Marital

Reasons for seeking therapy:

Please indicate what has led you to seek therapy at this time.

Are you currently under a Doctor's Care? If so, list the reasons.

Are you taking medication? If so, please list below.

*Are you thinking of hurting or killing yourself or someone else?

Submit Your Message:

Thank you for completing the Initial Intake. Once you have submitted your form, you can select your own appointment time by visiting our online calendar. Click here to make your appointment

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Christian Talk Therapy
Available Worldwide
via Text Messaging or Email

ph: 470-223-2276
savery@christiantalktherapy.com