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Intake form
Help us serve you better
Name
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Email address
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What brings you to therapy at this time?
Please select any areas you would like to focus on during therapy.
Please select at least one option.
Addiction
Anxiety
Attachment Trauma
Baby Loss
Childhood Trauma
Depression
Disordered Eating
Grief and Loss
Infertility
Neurodiversity
OCD
Peri-menopause/Menopause
Relationships
Trauma
Women's Health
Have you received therapy or counseling before?
Select
Yes
No
If yes, please briefly describe your previous experience.
What are your goals for therapy?
Do you have any medical conditions or take any medications that we should be aware of?
How did you hear about natalie McIvor?
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Referral
Social Media
Search Engine
Website
What is your preferred method of contact?
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Email
Phone
Text
Please indicate your availability for appointments.
Which service or services are you interested in?
Please select at least one option.
Trauma recovery
Couples counseling
Grief and Loss
Additional questions or comments
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