Prospective Client Form Name* First Last Phone*Email* How did you hear about me? (Internet search, referral, etc.)*Are you currently attending 12-step meetings?*YesNoAre you currently in therapy?YesNoPlease provide the therapist’s name(s).What are your top 2-3 goals for therapy -- what would success look like for you?Please check if you would like to receive updates: Yes, please add me to your mailing list. NameThis field is for validation purposes and should be left unchanged.