Modern Therapy Group
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Exploring your therapy options is the first step toward empowering yourself on your mental health journey
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NAME
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PHONE
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EMAIL
TYPE OF THERAPY
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Individual Therapy
Family Therapy
Couples Therapy
Teen Therapy
Preferred Days of Week for Sessions
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Time(s) for Sessions
7am-9am
9am-11am
11am-1pm
1pm-3pm
3pm-5pm
5pm-7pm
Areas of Concern
Addiction
ADHD
Adolescent and teen
Anxiety
Bipolar
Body image
Co-dependdency
Depression
Eating disorders
LGBTQ issues
Medication management
OCD
Porn addiction
PTSD or Trauma
Relationship issues
Sex addiction
Work related
Other
Preferred Therapist
Male
Female
LGBTQ
Psychiatrist
Member ID
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Insurance Provider
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PREFERRED SESSION
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In-person
Virtual
PAYMENT PLAN
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Insurance
Out of Pocket
*
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