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Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Location of Services *

In person in Adams Morgan NW DC

Telehealth

Either (whatever is available first)

Type of Service Requested *

Individual therapy

Couples therapy

Executive/Leadership Coaching

Group Therapy

When are you looking to have your sessions? *Therapists have varying availability. We do our best to pair you with a therapist who aligns, but your ideal choice isn't guaranteed. *

Early morning (before 9am)

Morning (9am-11am)

Early Afternoon (12pm-3pm)

Late Afternoon/Evening (4pm-6pm)

Night (after 6pm)

Weekends

What days of the week are you available for sessions? *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Do you have a preference for your therapist? *We cannot guarantee your preferred therapist will align with your availability, but we will do our best to match you. *

No preference

Brianna Blackshear (virtual only)

Amy Feeser

Jenna Parker

Carolyn Hoffmann (virtual only)

Please list the current symptoms experienced by the client.

Depressed Mood

Anxiety

Hopelessness

Suicidal Thoughts/Behaviors

Self Harm/Non-suicidal Self Injury

Trauma

Relationship Stress

Low Self Esteem

Chronic Illness

Postpartum Issues

Panic/Fear

Trouble Sleeping

Fatigue

Obsessions or compulsions

None of the above

Other

How did you learn about Out of the Margins?

Personal referral (friend, family, coworker, etc)

ZocDoc

Psychology Today

Social Media

Other