Beryl Olson Therapy | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Gender identity

Non-binary Woman (cisgender) Man (cisgender) Agender Transgender Trans woman Trans man Two Spirit Intersex Genderqueer Gender Fluid Unsure/Questioning Other/Not Listed

Age

11 or younger 12-17 18-24 25-34 35-44 45-54 55-64 65-74 75 or older

Ethnicity

Ethnicity reflects the cultural traditions, values, and practices that are shared by people across generations. When you consider your personal and familial cultural values, traditions, and practices, what labels best describe your ethnicity? (mark ALL that apply)

Arab, Middle Eastern, or North African—For example, Algerian, Egyptian, Iraqi, Jordanian, Sudanese, Syrian, Yemeni Asian or Asian American—For example, Asian Indian, Chinese, Filipino, Japanese, Korean, Nepalese, Vietnamese Black or African American—For example, Ethiopian, Haitian, Jamaican, Nigerian, Somalian Hispanic or Latino—For example, Colombian, Cuban, Dominican, Mexican or Mexican American, Puerto Rican, Salvadoran Native American or Alaska Native—For example, the Puyallup Tribe, Skokomish Tribe, Squaxin Island Tribe, Quinault Nation, Chehalis Tribe, or Nisqually Tribe Native Hawaiian or Other Pacific Islander—For example, Chamorro, Fijian, Marshallese, Native Hawaiian, Samoan, Tongan White or European American—For example, English, French, German, Irish, Italian, Polish Some other race, ethnicity, or origin I prefer not to answer

Ethnicity cont., Please specify what applies to you.

Reason for care

What is the reason for seeking care?

Anxiety Depression Grief Relationship issues Substance use Trauma Mood-related concerns Neurodivergence/Suspected Neurodivergence (Autism, ADHD, and beyond) Gender and identity exploration Other

What kind of care is being sought?

Individual therapy In- Person Group Art Therapy: April 2026 - May 2026 Other Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Administrative

Referral source

Enter how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times (Individual Therapy only)

Morning Afternoon Evening

Preferred modality

(Talk therapy, art therapy, interested in both, or unsure?)

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.