Intake Form

About this intake form:

I work primarily with queer and trans folks, people navigating chronic illness, and others who’ve been undeserved or harmed by conventional medical systems. My approach is collaborative, harm reduction-oriented, informed by the need for radical accessibility, and grounded in the understanding that healthcare trauma is structural and that means health happens in context —your body, your life circumstances, your communities, the systems you’re navigating.

These questions are the beginning of a conversation, not a form to complete correctly.

Your body has a story, and these questions are how I start to hear it. The more context I have, the better I can understand what’s actually happening – and the more I can tailor what we do together to your real life and your actual goals.

Answer from your current experience, your longer patterns, or both – whatever feels most true.

Skip anything that doesn’t feel relevant or comfortable. If something feels invasive or confusing, tell me – that’s worth knowing too.

What you share stays with me. I don’t share your information with insurance companies, employers, or anyone else without your explicit consent. If you ever want me to coordinate with another provider, just ask.

Before you fill this out, you should have received a separate document covering how we work together, confidentiality, and your rights as a client. If you haven’t seen that yet, let me know before continuing.