Name *

First Name

Last Name

Phone

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What are you hoping to work on in therapy?

Stress

Generalized anxiety

Panic attacks

Social anxiety

OCD

Mental health struggles during pregnancy

Postpartum depression

Postpartum anxiety or OCD

Other postpartum concerns

Individual work related to polyamory or consensual non-monogamy

Relationship therapy -- conflict and communication concerns

Relationship therapy -- infidelity

Relationship therapy -- issues related to polyamory or consensual non-monogamy

Depression

Other mood disorder

Trauma

Grief & loss

Body image or disordered eating

LGBTQIA+ concerns

Other (elaborate below)

Please confirm you are aware that Open Lines Counseling is an out-of-network practice. Payment is due at the time of service. We can provide Superbills to submit for out-of-network reimbursement. *

I understand