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Susan B Hagen

Image by Simon Wilkes

Intake Form

This form is not intended to address urgent mental health needs. In cases of emergency, contact emergency services (dial 911 in the US) or go to your nearest emergency department. The suicide hotline can be reached by phone or text at 988.

It's important to me that each client finds therapy that fits their present needs. If I believe my therapy could be a good match for you based on your responses, I will reach out to schedule a screening phone call at no cost. I aim to contact people within a week. If you don't hear from me, it means I don't think my therapy would be the best fit for you. If you anticipate that not receiving a response from me may be difficult for you, it may be worth considering not submitting the form.

Information

Interest in an RRP group:
Yes
No
Interest in individual therapy:
Yes
No

(I am currently only taking new clients for individual therapy who are also interested in the possibility of group therapy.)

I have difficulty connecting emotionally with self or others.
Yes
No
Most days I struggle with daily functioning (lateness, organization, follow through).
Yes
No
Therapy has not been beneficial for me in the past.
Yes, it has been beneficial
No, it has not been beneficial
I struggle with dissociation (feeling out of my body and not connected).
Yes
No
I am overwhelmed by stress most days.
Yes
No
I’m seeking short-term expediated change.
Yes
No
My problems are more situational than emotionally internal.
Yes
No
I do not know how childhood has impacted me.
Yes, I know
No, I do not know
I currently have legal problems.
Yes
No
I currently have problems of safety (domestic violence).
Yes
No
I’m currently in a contentious divorce.
Yes
No
I question my relationship to sex (shut down or compulsive).
Yes
No
I did not seek this out on my own, it was suggested to me to do childhood trauma work.
Yes, It was suggested to me
No, I sought this out myself
I’ve experienced suicidality in the last year.
Yes, I have experienced suicidality
No, I have not experienced suicidality this year.
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