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Counseling Intake Form

I’ve been in the business for over 15 years. I’ve worked with all populations with an extensive background in geriatrics. I pride myself on my down to earth demeanor and my ability to empathize with anyone. I come from the streets of North Philadelphia where we had to find a way out of no way. 

Counseling Intake Form

Please fill out this form prior to your first visit. This form is an initial way for the me to gather information about what you are experiencing, what you may need, and how I can best collaborate with you. This information is confidential between client and therapist. All information will be used for general assessment. I honor that sharing personal information in this way can be difficult and I will read this narrative with non-judgement and respect.

Contact Me

  • Philadelphia, Pa. 19144
  • itherapizeinc@gmail.com
  • 267-282-1189
  • 267-282-1189

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