Thank you, for completing our intake forms! You will be contacted soon.

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* 1. What is your name? If you chose to remain anonymous please provide your pronouns and preferred name.

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* 2. Please list your sport(s) and highest level of competition.

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* 3. How old are you?

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* 4. What city and state do you live in?

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* 5. What is your preferred telephone number and E-mail address?

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* 6. What is your sport psychology problem, issue or concern?

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* 7. Have you worked with a sport psychologist or psychologist before? If yes, please explain.

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* 8. Have you sustained any injuries in your sport(s)? Please explain.

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* 9. Have you ever been hospitalized for mental health reasons? Please explain.

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* 10. Information about you, including professional records that are required by the laws of (State) and the standards of my profession, will be kept strictly confidential. Please be aware of the following exceptions to the law: If you present a danger to yourself or others, I have a legal requirement to help keep you safe and a duty to warn potential victims. If you identify any known or suspected abuse of a child, an elder, or person with a disability, I am required by law to report such abuse to the appropriate state agency. If ordered by a judge in a court of law, I am required to provide access to your records; however, I would first assert legal privilege in an effort to protect your confidentiality. Further information regarding the protection of your confidentiality is found in the HIPPA compliance form. Please ask any questions necessary regarding the limits of confidentiality.