Branch Psychological | SimplePractice

Your info

First name

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Phone

Name you go by

Date of birth

Gender

State

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Reason for care

What is the reason you are seeking care?

Please select all reasons that apply to you currently

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Shock Trauma (from a recent single traumatic event) Developmental Trauma (trauma during childhood years that still affects you today) Adjustment difficulties (a recent change in your life has made it harder to function) Other

What modality of care is being sought?

Please select all types of services you are interested in receiving from Dr. Branch

Individual Psychotherapy (in-person) Individual Psychotherapy (by video) Somatic Experiencing (in-person) Somatic Experiencing (by video) EMDR (in-person) EMDR (by video) I am an SE student and want to do for-credit SE session (in-person) I am an SE student and want to do for-credit SE session (by video) Couples Therapy (ONLY provided in-person)

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

Please select all that are true for you:

I am in therapy now or recently I was in therapy in the past (more than 6 months ago) This will be my first therapy experience I am taking psychiatric medication now I have taken psychiatric medication in the past (more than 6 months ago) I was hospitalized for mental health reasons now or recently I was hospitalized for mental health reasons in the past (more than 6 months ago) Other

Administrative

How did you find Dr. Branch?

Please select how you learned about Dr. Branch

Google Search Somatic Experiencing Provider Directory (traumahealing.org) Provider Directory through insurance Psychology Today therapist directory Referral from another provider Referral from a friend/relative EMDRIA.org provider directory SE-Approved provider list Other

Billing & Payment

Payment method

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Client Preferences

Preferred appointment times

Dr. Branch's hours vary by day of the week. Please select the general time of day and days of the week that you would typically be available for an appointment:

Mornings Afternoons Evenings Mondays Tuesdays Wednesdays Thursdays Fridays Mornings, any day Afternoons, any day Evenings, any day

Is there anything that the practitioner needs to know?

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

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.