A Shift in Focus Therapy | SimplePractice

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Your info

First name

Last name

Phone

What is your age range?

What state will you be physically located in at the time of service?

CT FL MA RI SC

Reason for care

What are you seeking right now?

(check all that apply)

Ongoing counseling for ADHD or neurodivergence I think I have ADHD and would like more information Adult ADHD/Autism screening Comprehensive Adult ADHD/Autism evaluation I'm not sure and would like guidance

Are you currently experiencing any of the following?

(check all that apply)

Active suicidal thoughts Recent self-harm Active substance dependence Psychosis or mania None of the above

Are you currently in therapy?

I do not provide concurrent individual therapy.

Yes, I currently am in therapy but I'm seeking a new therapist. Yes, and I'll continue with them. I only want an evaluation for neurodivergence. No, I am not in therapy

Would you like a 20 minute phone consultation (not therapy)?

Consults are optional and must be reviewed and approved prior to scheduling.

Yes No/Not needed

Billing & Payment

Payment method

How do you plan to pay?

Client Preferences

Is there anything else you'd like me to know at this stage?

Please keep this brief (1–2 sentences). This is not a space for detailed history or urgent concerns.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.