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Nazzal Behavioral Health
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Intake form
Help us serve you better
Name
*
Email address
*
What type of therapy are you interested in?
Please select at least one option.
Individual Therapy
Couples Therapy
Recovery-Focused Counseling
What is your primary concern?
Select
Anxiety
Depression
Addiction
Stress
Relationship Issues
Other
Have you previously received therapy?
Select
Yes
No
Do you have any specific goals for therapy?
Which service or services are you interested in?
Please select at least one option.
Individual therapy
Recovery-focused counseling
Cognitive behavioral and solution-focused therapy
Caregiver and family consults
Clinical supervision for addictions counselors
Initial consultation for $150
Follow-up consultation for $100
Additional questions or comments
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