CHOSEN C & C Services | SimplePractice

CHOSEN C & C Services Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What feels like it’s quietly stacking right now?

By “quietly stacking,” I mean areas of your life that may not look like a crisis on the outside — but internally feel heavy, overwhelming, or hard to carry alone.

Limited to 600 characters

Where do you notice yourself over-functioning?

Over-functioning can look like taking responsibility for things that aren’t fully yours, solving problems before others ask, over-explaining, over-giving, or feeling anxious when you’re not in control.

Romantic Relationships Work or leadership roles Parenting, family or friendship dynamics Financial decisions Body/Health Faith Decision Making Emotional conversations Making sure everyone else is okay before you are

If nothing changes in 6 months, what concerns you most?

Imagine nothing improves and nothing worsens — everything simply stays the same. What concerns you most about that?

Limited to 600 characters

Are you primarily seeking:

Deep individual therapy Structured membership support Unsure — open to recommendation

What would make this investment worth it for you?

Administrative

Referral source

Enter how you were referred to our services

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.