Interested in Mental Health/Behavioral Health Services?

If you would like to schedule an appointment with Dahlia Michels, L.C.S.W., please upload the following documents:

Front and back of your insurance card
A valid ID (driver's license or other form of identification with your date of birth)
Completed Initial Intake - Potential Client form

Please allow up to 2 business days for us to review your information and confirm whether your health benefits cover our services. Please ensure that all required documentation—including a valid ID, the front and back of your insurance card, and a completed intake form—has been submitted. Once verified, we will reach out to discuss your benefits and schedule your appointment if you choose to proceed.

Healing Therapy Intake Form

Dahlia Michels L.C.S.W., Licensed Psychotherapist

Integrative Therapy- Mental Health & Behavioral Health

Welcome to Healing Therapy Center

Please complete this brief intake form to help us understand your needs and determine if our services are right for you. All information you provide is confidential.

Reason for Seeking Therapy

• Briefly describe the problem(s) or concern(s) that have brought you to therapy:

What is the problem that you are having that has brought you to reach out for therapy?

How did you hear about the Therapist? Referred by-

Short answer

Add your Goals for Therapy

• What do you hope to achieve by coming to therapy?

Your Answer

Previous Therapy

• Have you received therapy in the past? Yes / No

If yes, what was the focus, and what was helpful or unhelpful?

Your Answer

Personal Style and Therapy Fit

• Are you willing to work collaboratively within the structure of therapy sessions as determined by the therapist’s clinical expertise? Yes / No

This is a checkbox.

• How do you typically respond to frustration, stress, or conflict in relationships?

Your Answer

Personal Style and Therapy Fit

• Are you willing to work collaboratively within the structure of therapy sessions as determined by the therapist’s clinical expertise? Yes / No

This is a checkbox.

• How do you typically respond to frustration, stress, or conflict in relationships?

Your Answer

Questions

• Have you ever been diagnosed with a personality disorder? Yes / No

If yes, please specify:

Your Answer

Have you had difficulty maintaining personal or professional boundaries with others? Yes / No

If yes, please explain briefly:

Your Answer

Consent for Initial Consultation

Welcome to Healing Therapy Center. The purpose of the initial consultation is to assess whether we are a good fit to work together on the concerns you wish to address. This session is not a commitment to ongoing therapy but an opportunity for both you and the therapist to determine compatibility.

During this session:

• We will discuss your specific goals and reasons for seeking therapy.

• The therapist will evaluate whether they can offer the support you need within their scope of expertise.

• The therapist will explain their approach to therapy and the space they require to work effectively in your best interest.

By signing below, you acknowledge the following above and below:

• Therapy requires mutual collaboration, trust, and respect.

• The therapist reserves the right to decline ongoing therapy if it is determined they cannot provide the best support for your specific needs.

• You give consent to engage in this initial meeting to evaluate potential next steps.

Client Consent

By adding my name below with my initials and adding Date and Time, I understand that I am signing and that I agree to participate in the initial consultation with the understanding that this meeting is for assessment purposes. I acknowledge that I am also signing Healing Therapy Consent to Treatment for documentation purposes even though the therapist will decide/determine if they are able to provide the support I need for further and ongoing treatment and I give my consent to this process.

Name and Initials

Todays Date

Month

Day

Year

Time

HoursMinutes

Healing Therapy Intake Form

Dahlia Michels L.C.S.W., Licensed Psychotherapist

Integrative Therapy- Mental Health & Behavioral Health

Welcome to Healing Therapy Center

Please complete this brief intake form to help us understand your needs and determine if our services are right for you. All information you provide is confidential.

Reason for Seeking Therapy

• Briefly describe the problem(s) or concern(s) that have brought you to therapy:

What is the problem that you are having that has brought you to reach out for therapy?

How did you hear about the Therapist? Referred by-

Short answer

Add your Goals for Therapy

• What do you hope to achieve by coming to therapy?

Your Answer

Previous Therapy

• Have you received therapy in the past? Yes / No

If yes, what was the focus, and what was helpful or unhelpful?

Your Answer

Personal Style and Therapy Fit

• Are you willing to work collaboratively within the structure of therapy sessions as determined by the therapist’s clinical expertise? Yes / No

This is a checkbox.

• How do you typically respond to frustration, stress, or conflict in relationships?

Your Answer

Personal Style and Therapy Fit

• Are you willing to work collaboratively within the structure of therapy sessions as determined by the therapist’s clinical expertise? Yes / No

This is a checkbox.

• How do you typically respond to frustration, stress, or conflict in relationships?

Your Answer

Questions

• Have you ever been diagnosed with a personality disorder? Yes / No

If yes, please specify:

Your Answer

Have you had difficulty maintaining personal or professional boundaries with others? Yes / No

If yes, please explain briefly:

Your Answer

Consent for Initial Consultation

During this session:

• We will discuss your specific goals and reasons for seeking therapy.

• The therapist will evaluate whether they can offer the support you need within their scope of expertise.

• The therapist will explain their approach to therapy and the space they require to work effectively in your best interest.

By signing below, you acknowledge the following above and below:

• Therapy requires mutual collaboration, trust, and respect.

• The therapist reserves the right to decline ongoing therapy if it is determined they cannot provide the best support for your specific needs.

• You give consent to engage in this initial meeting to evaluate potential next steps.

Client Consent

Name and Initials

Todays Date

Month

Day

Year

Time

HoursMinutes