Is therapy right for you?

Contact Information

Full Name(Required)

First Last

Preferred Name (if different):

Email(Required)

Enter Email Confirm Email

Phone

Preferred Contact Method:

Phone

Text

Scheduling & Availability

Are you looking for:

Weekly therapy

Bi-weekly therapy

Unsure

Preferred Appointment Times (check all that apply):

Morning (8 AM–12 PM)

Afternoon (12–4 PM)

Evening (4–7 PM)

Weekends

Are you open to telehealth sessions?

Yes

Maybe

Are you currently experiencing any of the following? (Check all that apply)

Persistent sadness or low mood

Anxiety or excessive worry

Difficulty sleeping or staying asleep

Relationship challenges

Feeling overwhelmed or burned out

Major life transitions (e.g., grief, relocation, breakup, job change)

Difficulty concentrating or making decisions

Loss of interest in things you used to enjoy

None of the above

Have you been in therapy before?

Yes

If yes, what was helpful or unhelpful about that experience?

Reason for Seeking Therapy

What brings you to consider therapy at this time?

Therapy Goals

What would you like to work on or achieve through therapy?

Readiness to Begin

How soon are you looking to begin therapy?

Immediately

Within the next 2 weeks

Just exploring options

Would you like to schedule a free 15-minute phone consultation?

Yes

I already have / I'm ready to schedule my first session

Preference of Therapist

Do you have any preferences for a therapist (e.g., gender, cultural background, therapy style)?

Anything Else You’d Like Us to Know?

Contact Information

Scheduling & Availability

Reason for Seeking Therapy

Therapy Goals

Readiness to Begin

Preference of Therapist

Phone:

240.330.4361

Email:

admin@cercounseling.com

Address:

1 West Church St. Frederick, MD 21701.

Quick Links: