CONTACT – Ray Gjelsvik, LCMHC

123, Main Street, City, Country
+1 234 567 890
email@example.com

Ray Gjelsvik, LCMHC

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CONTACT

Ray Gjelsvik, LCMHC

Home
About
Policies
Resources
Workplace Disclosure
CONTACT

Client Full Name *

Guardian Full Name (if applicable)

Client Date Of Birth *Ages 16+ , Adults , Geriatric

Email Address *

Phone Number *

Preferred Method Of Contact-best way to reach Ray is EmailEmailPhoneCallText (limited to scheduling only)

Briefly, why are you currently seeking Therapy? (do not include any overtly personal information)

Have you been in Therapy before?YesNo

If yes, please briefly describe your previous therapy experience (e.g., type of therapy, duration, what was helpful/unhelpful).

Indicate any specific areas you are interested exploringAnxiety/StressDepression/Mood IssuesRelationship ProblemsGrief and LossTrauma / PTSDSubstance Use DisordersAnger ManagementSelf-Esteem & ConfidenceLGBTQia+ /transition / acceptanceLife TransitionsEating Disorders & Body ImageOther (Please Specify Below)

If you selected 'Other' above, please specify:

In general, how severe would you rate your symptoms that impact daily life?(none)1 – 10(severe)

What days and times are you available for sessions?due to variable roles, I am currently available FRIDAY only

Fridays ONLY

7am-7pm

AM/PM

Active or Prior Legal Matters? (court,custody,liasons, etc?)-note that both parents in a custody dispute must consent to their child entering services. Only full-custody may grant one consent. All parties must agreeYes (active)Yes(prior)No Legal Conflicts

Consent *

Yes, I consent to have Manta Clinical Therapy PLLC reach out to the above provided contact information to establish scheduling needs. Providing contact information does not indicate ‘active client status’. Active Client Status is granted after you are screened to begin Therapy Sessions, and complete all necessary forms and further consent to treatment.

LET IT BE KNOWN THAT I, Ray Gjelsvik, attest to using the below software for website creation. I disdain the use of AI for creative purposes. Kubio is a drafting software that has optional AI features. This website was created by myself, no other contractor, and in disregard of AI and its features