Therapy Inquiry Form | Quantum Conscious Healing

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Therapy Inquiry Form

All new patients are required to complete before scheduling

First Name

Last Name

Email

Phone

Date of Birth

What are some presenting problems or symptoms you are currently experiencing? (i.e, difficulty sleeping, overthinking, excessive worry, etc) What are you hoping to gain from therapy?

How often do you feel this ay? (i.e, daily, 2x/week, etc)

Have you ever been hospitalized for danger to self, others, or grave disability? * Required

Danger to Self

Danger to Others

Grave Disability

None Apply

Please select all that apply: * Required

Current suicidal ideation

History of suicidal ideation

Current homicidal ideation

History of homicidal ideation

Current substance abuse/dependence

History of substance abuse/dependence

Current self harm

History of self harm

None of the above apply

How will you be paying for services?

Member ID#

Group #

I accept terms & conditionsView terms of use

Thanks for submitting!

None of your information will ever be sold to any third party. When you provide your information, you are consenting to have QCH contact you via the information provided.

©2025 by Astral Family Therapy Inc.

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