New to Willow Tree?

Please fill out our New Client Form below so we can match you with the right therapist and schedule your first session.

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Name *

First

Last

Preferred Name (if applicable)

Phone *

By providing your phone number, you consent to receiving calls or texts regarding scheduling.

Email *

By providing your email, you consent to receiving scheduling communications.

Date of Birth *

We need this to create your personalized client portal access.

Address / City / State / ZIP *

Reason for Requesting Service: *

Previous Coaching/Therapy?

If so, with whom? (CSAT, CCPS, CPTT, other?)

Type of Service Requested: *

• Treatment for Sexual Addiction
• Treatment for Partner Betrayal Trauma
• Healing or Recovery Groups
• Couples Treatment
• Therapeutic Intensives

In-person or Telehealth availability? *

• In Person Only
• Virtual Only
• Both

How do you feel your current situation is impacting your daily functioning (sleep, work, relationships, emotions)? *

On a scale from 0-5, 5 being highest, how would you rate your current level of functioning? *

Are you currently experiencing symptoms like anxiety, depression, flashbacks, or difficulty managing emotions? (copy) *

that Date creating

Do you have a history of trauma that you’d like to explore and heal from? *

Have you been diagnosed with any mental health conditions in the past? *

Are you looking for help creating structure, accountability, or tools to move forward? *

Are you seeking support in rebuilding a relationship? *

Are you primarily looking for guidance and strategies or deep emotional processing? *

In your opinion, are you at the beginning, middle, or later stages of recovery or trauma healing? *

If seeking Couples therapy, are you currently in therapy or coaching?

If applicable, please describe previous couples therapy experience.

Referred By / How Did You Hear About Us?

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