Online Registration Form
May we leave a message?
How did you find out about Refection Therapy Services?
Physician Contact History
Are you currently under the care of a psychiatrist?
If yes, please enter the psychiatrist you are seeing:
Psychotropic Medication History
General Therapy Experience
Have YOU ever received mental health services (counseling/therapy) in the past?
Have any of IMMEDIATE FAMILY MEMBERS listed on this form received mental health services (counseling/therapy) in the past?
All information on this form is considered confidential and will not be shared with anyone other than your therapist unless permission is granted through written consent.