Therapy Service Request Form | Joi McCreary, MA, MFT, CLC, RYT

Greetings! Please take a moment to fill out this questionnaire. This is the first steps too requesting therapy service(s). Once we receive this form, we will respond via email with next steps. Should we assess that your request is out of our scope or availability, we will offer community referrals. Information you provide here is held to the same standards of confidentiality as our sessions. This form is not a diagnostic instrument and is only to be used within the context of your requested services.

We do NOT operate as an emergency crisis agency. If you are experiencing suicidal or homicidal thoughts or behaviors; contact 911, go to the nearest stress center or emergency room immediately.

Disclosure: Joi McCreary, MA, MFT is a master's level pre-licensed professional who practices counseling as a Couples, Marriage and Family Therapy resident under licensed clinical supervision of Anita Adams LMFT (35001887A). JoiMcCreary.com, JoiOlogy LLC, JoiOlogy 5155 LLC and the supervising locations are in no other way affiliated, in partnership or endorsing the practices outside of clinical supervision and full licensure requirements.

How did you hear about us? *

Type of Therapy Requesting *

Individual Therapy

Couples and/or Marriage Therapy

Family Therapy

Group Therapy

When would you like to start? * +

Date of birth: * 🛈 +

First Name *

Last Name *

Street Address (Include Apt. or Ste. #) *

City *

State *

Zip Code *

Phone Number *

Is it ok to leave a message? *

Email Address *

Do I have permission to email you? * 🛈

Employment Status *

Identified Gender

Pronouns

Relationship status

Single	Partnered	Living Together/Cohabitating
Engaged	Married	Separated
Divorced	Widowed	Please specify if your status is not listed: Please specify if your status is not listed: