Let’s Connect Name * First Name Last Name Date of Birth * Phone * Email * Relationship to client * What are you seeking care for? Please check all that apply. * Depression/Anxiety/OCD/Mood Regulation/PTSD Low Energy/Fatigue/Brain Fog Attention/Focus/Impulsivity Addictions/Substance Use Psychosis/Schizophrenia/Schizoaffective Natural & Holistic Strategies for Life Optimization Stress/Burnout Coaching and Support Life transitions Sleep/Insomnia Men's Health Concerns Weight Management Check all that are applicable * In therapy now In therapy in the past Taken psychiatric medication now or in the past Hospitalized for psychiatric reasons now or in the past Attempted suicide in the past N/A How did you hear about Steadfast Wellness Center * Therapist referral (list below) Primary Care Provider (list below) My Insurance Carrier's Website Psychology Today Profile Internet search/Google Friend/Family/Current or past client Social Media Other (list below) Referral source (if referred by therapist, provider, other) What are your goals for consultation and care? What are you hoping to get help with? Anything else you would like us to know? * What is your insurance carrier? * Payment Info Steadfast Wellness Center does not participate in any insurance plans at this time. This allows us to provide more personalized care not limited by insurance plans. I understand that I am responsible for payment in full at the time services are rendered outside of the initial free 15 minute consultation. Yes No Thank you!
