Request appointment | The In-Between

What is the reason for seeking care?

1-3 sentences as to what's going on tright now that prompted the need for therapy

What kind of care is being sought?

Psychotherapy for just myself Psychotherapy for me and my partner(s) Group psychotherapy for just myself Group couples psychotherapy for me and my partner

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

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