waitlist form | Safespace 1

First name

Last name

Email

Phone

Are you above the age of 18?

Yes

No

Are you seeking therapy for yourself, of your own volition — not at the request or suggestion of someone else?

Yes, I am choosing this for myself

No, someone else has suggested I should do this

I’m not sure

What brings you to therapy at this time?

What is it about my work or this practice that drew you to me?

How would you describe your current relationship with emotional intensity and self-exploration?

I’m not ready to feel big emotions

I want support but prefer to stay surface-level

I’m open but hesitant

I’m ready to feel what’s there

I’m actively seeking deep emotional transformation

Have you had therapy before? If so, what type and how did you find it?

How soon are you hoping to begin one-on-one therapy (if space becomes available)?

As soon as possible

Within 1–2 months

I’m happy to wait

Just exploring for now

I understand that this form is not a guarantee of therapy and that I will be contacted only if a space opens and it feels like a mutual fit.

I agree

Safe Space