client portal - Tarajitherapy

Welcome to Taraji Therapy

Begin Your Journey to Wellness – New Client Registration

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Name *

First

Last

Email *

Phone

Date of birthday

mm/dd/yy

Address

Services You're Interested in

What are your Primary Concerns

please share what you will like support with (e.g., Anxiety, Relationship issues, trauma, Life transitions, etc.)

Have You Attended Therapy Before

session Preferences

Date / Time

Date

Time

select Preferred day/Time

Before / Us

Emergency Contact Name *

First

Last

Emergency Contact Phone

Relationship to You

How Did You Hear About Us

Checkboxes

I Consent to: Receiving Care from Taraji Therapy, Sharing the information provided in this form, Receiving appointment reminders Via Email//SMS and receiving the practices confidentiality and privacy policies during my first session. I understand that therapy except in cases required by law.

Providing safe, compassionate, and evidence based therapy for individuals, couples, families, groups, and communities.