New Client Questionnaire

Contact and General Information

Preferred Name of Client*

Pronouns

For Child Clients - Caregiver Name

Any information submitted is only shared with me, and you are not signing up for any kind of automated or spam communication! If you don't put anything, I won't be able to reach you!

Phone

Preferred Contact Method*

Text

Phone Call (Agree to Receive a Voicemail)

Where do you live? (City and State)*

I am only licensed to provide therapy to folks who are physically located in Missouri or Minnesota.

Where would you like to meet?*

In-Person (Kansas City, MO in the Crossroads)

Virtual (Living in MO or MN, only available for clients 12 and older)

How did you hear about me?*

Tell Me a Bit About You

What brings you to therapy now?*

Do you take any medication for mental health purposes? If so, what do you take, and how does it help?*

Have you been previously received any diagnoses? If so what are they? *

What services are you most interested in receiving? You can read more on the Services section of my website!

Talk Therapy

EMDR

PC-Care / Family Therapy

Couples Therapy

Child-Led Play / Therapy for a Kiddo

Would you like to schedule now or have me contact you?

Schedule Now!

Please reach out to me :)

Book 15 Minute Consultation

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allie@alucatherapy.com

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MN License: cc2794

MO License: 202401693

Missouri Practice | Minnesota Practice

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