Welcome to PATH Therapy. Please complete this short form so we can learn more about your needs and help

match you with the right clinician.

Important: This form is not monitored 24/7 and is not for emergencies. If you are in immediate danger or may harm

yourself or someone else, call 911 or go to the nearest emergency room. If you are experiencing suicidal thoughts

or emotional crisis, call, text, or chat 988 for the Suicide & Crisis Lifeline.

Tell us about the person seeking care

Are you currently having thoughts of harming yourself or ending your life?

Not currently, but I have in the past

Yes, and I may need immediate support

Yes, but I do not have a plan or intent

Form is not monitored 24/7. If you answered yes please call 911 or 988

Have you been to therapy before?

Yes, I am currently in therapy

Yes, but not currently

Do you have a preference for how you recieve care?

In-person

Either in-person or telehealth

Telehealth / Virtual

No preference

Is there anything else you would like us to know before we contact you?

Phone *

Email *

By checking this box, I consent to receive non-marketing text messages from [BUSINESS NAME] about [USE_CASE_FROM_CAMPAIGN_DESCRIPTION]. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from [BUSINESS NAME] at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.