Intake Form | Begin Your Healing Journey

First name

Last name

Preferred Name / Nickname (if any):

Email

Phone

Pronouns

Birthday

Age

Preferred Method of Contact:

Phone

Email

Text

Emergency Contact Name

Emergency Contact Phone

Racial / Ethnic / Cultural Identity (optional):

Language(s) Spoken at Home:

Please select any that apply to you:

I’m navigating grief or loss

I’m seeking family healing or reconciliation

I’m managing anxiety, trauma, or depression

I’m looking for creative healing outlets

I’m exploring spiritual or emotional wellness

I’m interested in becoming a peer leader

Other

What brings you to Your Healing Matters at this time?

Have you previously participated in therapy, coaching, or community healing spaces?

Yes

No

Prefer Not To Say

If yes, what was helpful or unhelpful about those experiences?

Do you have any accessibility needs we should know about (e.g., mobility, translation, sensory sensitivity)?

Anything else you’d like us to know before getting started?

YHM Intake Form