Rebecca Van Tassel | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Reason for care

What brings you to therapy right now?

A sentence or two is plenty. We'll have time to talk about this in more detail during our call.

What do you want to get out of therapy?

What would you like therapy to do for you? What are you hoping might change? You don’t need to have this all figured out—just share whatever comes to mind.

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.