Safe Harbor Therapy | SimplePractice

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

State

Select the state you live in

Pronouns

Reason for care

If seeking therapy for someone else, what is your relationship to them?

What brings you to therapy at this time?

Feel free to share as much or as little as you're comfortable with.

Limited to 600 characters

Administrative

Next Steps

Would you like Jeanette to call you for a free 15-minute consultation, or would you like to proceed with scheduling? If you proceed with scheduling, you'll receive an email with intake forms to complete before your first session.

A brief call with Jeanette Proceed with scheduling

Referral source

How did you hear about this practice? (Optional)

Search engine (Google, Bing, etc.) Psychology Today Referral from another provider (doctor, psychiatrist, therapist, etc.) Referral from a school (counselor, teacher, etc.) Word of mouth

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.