Everything you discuss on this form, or in the future with an Umbrella Collective therapist, will be kept confidential. Your privacy is important to us, and we are also trying to make sure that our services are a good fit for you. Please also know that legally there are a few situations in which therapists are mandated by law to break confidentiality: those being situations involving child abuse, elder abuse, or a plan to hurt yourself or others. If you are in a crisis please go to http://coloradocrisisservices.org/, or call 1-844-493-8255.

Preferred Name *
Preferred Name
Helps us to identify you correctly
Phone *
Please let us know your preferred way of being contacted
How do you plan to pay for therapy? (current available options listed below) *
Date of Birth *
Date of Birth
Do you currently or have you struggled with drugs and/or alcohol in the past? *
If you are suicidal please go to your nearest emergency room or walk-in crisis center (3180 Airport Rd, Boulder, CO 80301) or call 911 or the crisis line: 1-844-493-4255
Have you ever attempted suicide? *
If you are in a crisis please go to http://coloradocrisisservices.org/
Have you ever been hospitalized for mental health reasons? *
Would you be open to Group Therapy?
Therapeutic groups provide opportunity to create powerful healing experiences for people.
This could be how you identify, certain preferences regarding therapists, or major stressors in your life.