Intake form

Help us serve you better

Complete the required fields and share your responses with us.

Full Name: *

Email address *

Phone number *

Reason for Seeking Therapy:

Have you been in therapy before?

Yes

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Please note: This form is not for emergency use. If you are experiencing a crisis or need immediate assistance, please call 911 or your local emergency hotline. This form is intended for scheduling consultation appointments only.

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Reminder: This is not a secure platform for transmitting sensitive health information. Please refrain from sharing detailed personal health information through this form. You will have the opportunity to discuss your health details securely during your initial consultation.

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By submitting this form, you consent to allow Jasmine Vanantwerp, LCPC, to use the information provided to contact you regarding your request for consultation. Your information will be handled with confidentiality and respect, in accordance with our privacy policy.

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