How did you hear about Kyndra Lina? *

Work

School

Google

Social Media

Family Referral

Friend Referral

Insurance Provider

Therapy for Black Girls

What type of appointment would you like to schedule? *

Individual Sessions

Couple Sessions

Family Sessions

Are you aware that we are 100% virtual and currently ONLY offer online sessions? *

Yes

No

Are you aware that we only serve clients who reside in the state of Georgia? *

Yes

No

Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred Method of Contact *

Cell Phone

Email

Client's Date of Birth *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Do you have insurance? *

Yes

No

Subscriber Name *

First Name

Last Name

Subscriber Date of Birth *

MM

DD

YYYY

Please check all that apply: *

None

Allergies

Anemia

Angina

Anxiety

Arthritis

Asthma

Atrial Fibrillation

Benign Prostatic

Blood Clots

Cancer

Cerebrovascular Accident

COPD (Emphysema)

Coronary Artery Disease

Crohn's Disease

Depression

Gallbladder Disease

GERD (Reflux)

Hepatitis C

Hyperlipidemia

Hypertension

Hypertrophy

Irritable Bowel Disease

Liver Disease

Migraine Headaches

Myocardial Infarction

Osteoarthritis

Osteoporosis

Peptic Ulcer Disease

Renal Disease

Seizure Disorder

Thyroid Disease

Other

Please check all that apply: *

Adopted

Alcoholism

Allergies

Asthma

Arthritis

Blood Disease

CAD (Stroke)

Cancer

CVA (Stroke)

Depression

Developmental Delay

Diabetes

Eczema

Hearing Deficiency

Hyperlipidemia (High Cholesterol)

Hypertension (High Blood Pressure)

Irritable Bowel Disease

Learning Disability

Mental Illness

Tuberculosis

Obesity

Osteoarthritis

Osteoporosis

PVD

Renal Disease

Other

Have you seen a counselor, psychologist, psychiatrist or other mental health professional before? *

Yes

No