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  • Emergency Contact

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  • WHY ARE YOU SEEKING THERAPY?

  • (Check all that apply)
  • YOUR STORY

  • YOUR GOALS

  • PERSONAL STRENGTHS

  • YOUR INTERESTS

    One of the ways we personalize therapy is by incorporating what matters most to you.
  • MENTAL HEALTH HISTORY

  • CURRENT MEDICATIONS

  • MEDICAL HISTORY

  • TRAUMA HISTORY

    Only share what you feel comfortable sharing today.
  • SUBSTANCE USE

  • FAMILY & RELATIONSHIPS

  • EDUCATION & EMPLOYMENT

  • JUSTICE INVOLVEMENT

    (Optional)
  • HOUSING

  • SPIRITUALITY

  • SAFETY QUESTIONS

    If yes, therapist will complete additional safety assessment.
  • CULTURE & IDENTITY

  • WHAT SHOULD I KNOW ABOUT YOU?

  • THERAPIST-CLIENT PARTNERSHIP

    At Butterfly Counseling Services, we believe therapy works best when it is a partnership. We will work together to identify your strengths, set meaningful goals, and create a therapeutic experience that reflects who you are. Sometimes that may mean meeting in a traditional office. Other times, when clinically appropriate, it may involve incorporating activities such as walking outdoors, creative expression, or other approaches that align with your interests and therapeutic goals.
  • CONSENT

    I certify that the information provided is accurate to the best of my knowledge.
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