Tapped Out Counseling | SimplePractice

Tapped Out Counseling Send Message

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Chronic illness and/or disability Depression Grief Identity Development Intergenerational Trauma Life Transitions Neurodivergence Relational Issues Trauma Other

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

Client Preferences

Preferred appointment times

Please the days and times you are available

Is there anything else that you would like me to know?

For example: what you'd like to focus on, important identities you'd like to share, payment questions, etc.

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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.