Step 1 of 18

Age Check

What is your date of birth?(Required)

Month

Day

Year

If you are under 18, click here for important information and support resources

We hear you wanting support, and that matters. This is a reminder that before we can complete enrollment and begin sessions for teen therapy, we’ll need written consent from a parent or legal guardian…

988 Suicide & Crisis Lifeline
Call or Text: 988
Crisis Text Line
Text HOME to 741741
Teen Line
Call: 1-800-852-8336
NAMI Teen & Young Adult HelpLine
Boys Town National Hotline
Call: 800-448-3000
The Trevor Project
Call: 1-866-488-7386
211 United Way
Dial 211
Emergency Services
If a teen is in immediate danger, call 911 immediately.

What state are you located in?

State(Required)

We’re actively working to provide therapy services in your state. Fill out the rest of this intake and share your contact information at the end and we’ll be back in touch as soon as matching services are available in your area.

Ethnicity

How would you describe your race and/or ethnicity?(Required)

Please select all that apply, or feel free to describe in your own words.

White

Black / African American

African or African Diaspora (e.g., Nigerian, Ethiopian, Haitian, Afro-Caribbean)

Hispanic / Latino/a/x

Middle Eastern or North African

Asian (e.g., Chinese, Indian, Filipino, Vietnamese, Korean, Japanese)

Native Hawaiian or Pacific Islander

American Indian or Alaska Native

Multiracial / Mixed Race

Other

I prefer not to say

I describe my race/ethnicity as:(Required)

Is your racial, ethnic, or cultural background something you would like your provider to know more about as part of your care?(Required)

Yes

I’m not sure yet

Gender Identity

How do you identify your gender?(Required)

Woman

Man

Non-binary

Transgender

Prefer not to say

Other

I describe my gender as:(Required)

You should feel assured that your therapist sees and supports you for who you are. These questions help us match you thoughtfully.

Sexual Orientation

How do you identify your sexual orientation?(Required)

Straight

LGBTQIA+

Questioning

Prefer not to say

Other

Remember: these questions are only used to help us match you thoughtfully.

Select which LGBTQIA+ orientation you identify as:

I describe my sexual orientation as:

Spiritual or Religious Alignment

Do you identify with a religious or spiritual practice?

Yes

Prefer not to say

Which religious or spiritual practice do you identify with?

Describe the religious or spiritual practice you identify with:

Relationship status

Length of your relationship:(Required)

Are you living together?(Required)

Yes

Marital status:(Required)

Dating

Engaged

Married

Separated

Divorced

Other

Describe your marital status:(Required)

Previous therapy

Do you have previous experience with couples therapy?(Required)

Yes – it was helpful

Yes – it was not helpful

Have you been in individual therapy before?(Required)

Yes

Conditions & symptoms

Have you ever been diagnosed with a mental health condition?(Required)

Yes

Prefer not to say

Please list the mental health conditions you have been diagnosed with:(Required)

Have you or your partner ever been diagnosed with a medical condition that impacts your mental health?(Required)

Yes

Prefer not to say

Please list the medical conditions that you or your partner have been diagnosed with that impact your mental health:(Required)

Are you or your partner experiencing symptoms associated with any of the following life stages?

Check all that apply:

Menopause/perimenopause

Post-partum

Andropause

Individual concerns

What are you current individual concerns?(Required)

Anxiety or depression

Trauma-related symptoms

Substance use concerns

Anger/emotional regulation issues

Current crisis or instability

None

Prefer not to say

Other

Check all that apply:

Describe what other individual concerns you have:

Couples therapy

What are the main reasons you’re seeking couples therapy right now?

Check all that apply:

Communication problems

Frequent arguments

Emotional distance or disconnection

Trust concerns

Infidelity or betrayal

Parenting stress

Blended family challenges

Financial stress

Life transitions (moves, illness, loss, etc.)

Intimacy or affection concerns

Considering separation/divorce

Other

List what other reasons you are seeking couples therapy for:

Couples therapy (continued)

Which statement best reflects how you feel about the relationship right now?(Required)

I want to repair and strengthen it

I’m unsure what I want

I’m leaning toward separation but open to therapy

I’m here mostly because my partner wants to be

Have you and your partner discussed separation or divorce recently?(Required)

Yes – briefly

Yes – seriously

Do you have children?(Required)

Yes

Which of these best describes your parenting situation?(Required)

Expecting a child

New parents (child under 1)

Parenting young children (1-5)

Parenting school age children (6-12)

Parenting teenagers (13-18)

Parenting adult children (18+)

Co-parenting/Separate Households

Couples therapy (continued)

How well do you feel you and your partner handle stress together?(Required)

Very well

Well

Fair

Poorly

How often do disagreements occur?(Required)

Rarely

Sometimes

Often

Very often

When conflict happens, how is it usually handled?(Required)

We resolve it

It goes unresolved

One or both withdraw

It escalates

Varies

Couples therapy (continued)

During conflicts, do any of the following occur?(Required)

Check all that apply:

Yelling or raised voices

Name-calling or verbal attacks

Stonewalling or shutting down

Leaving the home during arguments

Threats of separation or divorce

Destruction of property

Physical intimidation

None of the above

Is there domestic violence currently happening in the relationship?(Required)

Yes

Prefer not to say

Couples therapy (continued)

How connected do you feel emotionally to your partner?(Required)

Very connected

Moderately

Slightly

Not connected

Are there concerns about physical or sexual intimacy?(Required)

Yes – physical intimacy

Yes – sexual intimacy

Prefer not to say

How much trust do you currently feel in the relationship?(Required)

Strong trust

Mostly

Some

Very little

Couples therapy (continued)

Will both partners attend sessions from the same location?(Required)

Yes

What are you hoping therapy will help you decide or achieve?

Check all that apply:

Improve communication

Reduce conflict

Repair trust

Clarify whether to stay together

Co-parent more effectively

Prepare for separation respectfully

Looking for a provider who will:

Check all that apply:

Teach skills

Explore dynamics

Challenge beliefs

Assign homework

Set goals

Mediate conflict

No preference

Finding your right fit

Would it feel meaningful to work with someone who shares any of these aspects of identity or experience?

Check all that apply:

Female

Male

LGBTQIA+

Provider or color

Age 45+

Religious or spiritual alignment

Non-religious

No preference

Something not listed above

What other shared aspects would you find meaningful?

Specialized support

We believe everyone deserves great care. Do any of these apply to you?

Check any or all that apply:

I’m a veteran

I’m experiencing PTSD

I’m struggling with post-partum depression

I’m going through menopause/perimenopause

Final Step: Confirm & Continue

How we’ll connect: Care is provided via telehealth using secure electronic communication. You may withdraw consent at any time.

Consent to Treatment: I understand that I am consenting to receive mental health services through Breathable.

Privacy & HIPAA: My information is protected under HIPAA. I have reviewed the Notice of Privacy Practices.

Non-Emergency Disclaimer: Breathable is not an emergency service. If I am in crisis, I will call 911 or 988 in the U.S.

I agree to the Terms of Service and Privacy Policy.

Telehealth consent(Required)

I consent to care via telehealth.

First & Last Name:(Required)

First Last

Email Address:(Required)

Enter Email Confirm Email

This is how we’ll get back in touch with you once we’ve matched you with a therapist.

Phone Number:

Breathable does not provide clinical or therapeutic services. Licensed therapists deliver all therapy services independently. The platform charges through the Breathable platform. The total price you pay includes the professional fees for the therapy services, which are collected on behalf of the therapist and paid to the therapist, and separate administrative and technology fees for the non-clinical services, which are included in the total retail price paid by the customer. Administrative fees are not paid to your therapist but are included in the total retail price that the Breathable platform makes possible and that enables you, as the customer, to have seamless access to therapy services.