Colleen Stone | SimplePractice

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Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What brings you here today? (select all that apply)

Anxiety/ Overwhelm Depression/ Low Mood Stress/ Burnout Grief/ Loss Divorce/ Seperation Support Considering Divorce (Dicernment) Relationship Challenges Couples Therapy Infidelity/ Betrayal Recovery Co-Parenting Support High-Conflict Relationship Dynamics Attention/ Focus Difficulties Life Transitions (Divorce, Retirement, Next Chapter Transition) Identity/ Purpose/ Direction Major Life Changes Behavioral Concerns (self or child) Substance Use/ Coping Concerns Not sure / I’d like to discuss this

Have you experienced any of the following in the past or currently? (Select all that apply)

Currently in therapy Have participated in therapy in the past Currently taking psychiatric medication Have taken psychiatric medication in the past Hospitalized for mental health reasons recently Hospitalized for mental health reasons in the past Known neurologic or genetic condition History of suicidal thoughts or attempts None of these apply

Are you currently experiencing thoughts of harming yourself?

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

Yes No

What type of support are you seeking?

Individual Therapy Couples Therapy Relationship Intensive (multi-hour) Coaching/Personal Growth Not Sure Yet

Are you located in California? (important for therapy licensing)

Yes No

Client Preferences

Preferred modality

If you would like in-person services, we schedule 7 a.m.-5 p.m. Tuesdays and Wednesdays and 7 a.m. to 12 noon on Thursdays. Which of those days and times do you prefer?

For example: what you'd like to focus on, insurance or payment questions, etc.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.