Intake form

Help us serve you better

Name *

Email address *

What is your age?

What is your gender?

Which of the following best describes your current situation?

Please select at least one option.

Deconverting from a religion

Deprogramming from a belief system

Survived narcissistic abuse

Seeking support for emotional distress

Looking for community support

How did you hear about us?

Tell us what's happening

Have you previously attended therapy or support groups?

If yes, please briefly describe your experience.

What are your preferred days and times for sessions?

Additional questions or comments

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