Contact Team Ampersand

Your Name (req'd)

Your Email Address (req'd)

Your Phone Number (req'd)

Your Gender (req'd)
MaleFemaleUndisclosed

Your Address (req'd)

How Did You Hear About Us? (req'd)

How Would You Like to be Contacted for Follow-Up?
{Please note the follow up appointment will take about 45-60 minutes}
PhoneEmail

Your Occupation

Referred By:

The nature of your responses to the following questions will go a long way in assisting our understanding of your truest needs. Your time, thoughtfulness and honesty in completing this overview is greatly appreciated.

What brings you to seek wellness counseling? (req'd)

What services are you interested in? (req'd)

How are you feeling mentally, physically, and emotionally today, and in recent months? (req'd)

What behaviors/habits do you currently engage in regularly that you believe support your health? (Please list) (req'd)

What potential obstacles do you foresee in your health journey? (req'd)

What three (3) expectations do you have from working with Ampersand? (req'd)

What do you love to do (what brings you joy)?

What if anything should we know about you?

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