Schedule an Appointment with Indigo!

Name *

Name of person filling out this form

First Name

Last Name

Client Name *

Name of person receiving therapy services

First Name

Last Name

Client Date of Birth *

MM

DD

YYYY

Is client a minor? *

Yes, client is a minor.

No, client is an adult.

Phone Number *

Please provide a phone number you would be comfortable being contacted on regarding therapy services.

(###)

###

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Presenting Concerns *

If you select "Other," please describe your presenting concern in the next box.

Anxiety

Depression

Disordered Eating Behaviors

Grief

LGBTQ+ Affirming Therapy

Life Transitions

Personality Disorder

Relationship Issues

Self-Esteem

Stress

Trauma

Other

Session Frequency *

How often are you wanting to meet for therapy?

Weekly

Every Two Weeks

I'm not sure