Patient Intake Form

Interested in being matched with a trauma therapist? Fill out some info and we will be in touch shortly! All responses are confidential.

Name

First Name

Last Name

Phone

(###)

###

####

Please provide any information and preferences you may have for a provider (i.e. female therapists only, etc.) that can help us in matching you with a therapist.

What are your preferences for therapy?

In-person

Remote

No preference

How do you plan on paying for therapy?

If you plan on using insurance, who is your provider?

We will use this information to match you with a therapist that takes your insurance.

Is there anything else you want us to know?

Get in touch.

If you have any questions or concerns please leave us a message, and we will get back to you via email.

If you are a trauma healthcare provider and would like to be included in our referral network, please send us a message.

Patient Intake Form

Get in touch.

ReGroup

Sign up to get matched with a trauma therapist.