Office Phone Number *

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Office Fax Number

if applicable

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Client's Name *

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Client's Phone Number *

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How should we contact the client? *

Calls and texts will come from 814-273-6270. Emails will come from hello@metamorphosiscounseling.net. Calls are made between 9am and 5pm Mon-Fri. Selecting text or email will likely result in the quickest response time.

Call

Text

Email

What are the main areas of concern? *

Please select all that apply.

Academic/school stress

Anxiety

Anger

Autism concerns

Body image issues

Child/teen issues

Depression/sadness

Disordered eating

Domestic abuse/IPV survivor

Emotionally immature parents

Going through a big life change (e.g. starting college, had a baby, getting divorced, etc.)

Grief

LGBTQIA+ concerns (e.g. transitioning, coming out to family/friends)

Low self-esteem

Panic

People pleasing tendencies

Physical symptoms (e.g. shakiness, hives, difficulty breathing, heart palpitations, etc.)

Self-harm

Stress

Substance use problems

Trauma

Unsatisfying relationships

Other (please detail below)