What are you looking to work on? Select all that apply
*
What is your availability for sessions? Please select all that apply.
*
Motivation to Begin
From 1-5, 5 being ready to begin, please select your motivation to begin treatment.
Name
*
First Name
Last Name
Age?
*
What are your pronouns?
*
Email
*
Phone
(###)
###
####
How do you prefer us to reach you?
*
-
Email
Phone
Text
Are you currently in New York State?
*
Yes
No
Are you currently engaging in self harming or injurious behaviors? (cutting, burning, etc)
*
-
No
Yes
Is there anything else you'd like us to know?
LGBTQ+ Match Form Complete!
Thank you for your interest in working with an LGBTQ+ therapist at Aspire Psychotherapy. Our care team will reach out to you within 12 hours to schedule the 15 minute phone call. We look forward to learning more about your goals.
Warmly,
The Aspire Psychotherapy Team
