Step 1 of 14

Age Check: How old is your teen?

What is your teen's date of birth?(Required)

Month

Day

Year

Location Verification

Which state do you currently live in?(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 teen's 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 teen's race/ethnicity as:(Required)

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

Yes

I’m not sure yet

Gender Identity

How do you identify your teen's gender?(Required)

Woman

Man

Non-binary

Transgender

Prefer not to say

Other

I describe my teen's 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.

What brings you here?

What prompted you to seek therapy for your teen?(Required)

Check all that apply:

Persistent sadness or low mood

Anxiety, worry, or frequent fearfulness

Stress or feeling overwhelmed

Anger, irritability, or emotional outbursts

Changes in school performance or attendance

Social withdrawal or friendship challenges

Family conflict or communication difficulties

Significant life changes (divorce, move, illness, loss)

Exposure to or experience of a stressful or traumatic event

Concerns about identity, confidence, or self-esteem

Grief or loss

Other

Let us know what else might have brought you here:(Required)

How long have you noticed these concerns?(Required)

Less than 3 months

3–6 months

More than 6 months

On and off over time

Previous therapy

Has your teen ever participated in therapy or counseling before?(Required)

Yes, briefly

Yes, for several sessions

Yes, long-term

Not sure

School

Is your teen currently enrolled in school?(Required)

Yes, attending regularly

Yes, but attendance has been inconsistent

No (please explain)

Please explain why your teen is not enrolled in school:(Required)

Current living situation

What is your teen’s current living situation?(Required)

Lives with both parents

Lives with one parent

Split custody between parents/guardians

Other

Describe your teen's current living situation:(Required)

Family changes

Are there any recent or ongoing family changes that may be affecting your teen?

Check all that apply:

Divorce or separation (current or recent)

Blended family or new household members

Serious illness or medical issues in the family

Death or significant loss

Financial or housing instability

No major changes

Other

What are the other family changes that might be affecting your teen?

Diagnosed disorders

Has a professional ever shared concerns or diagnoses related to your teen’s mental or emotional health?

Check all that apply. It’s okay if you’re not sure.

ADHD / attention-related concerns

Anxiety

Depression

Trauma-related concerns

Autism spectrum

OCD

Eating-related concerns

Mood-related concerns (e.g., bipolar)

Other diagnosis or concern

No diagnosis

Not sure

What other concerns or diagnoses have been shared by a professional relating to your teen's mental and emotional health?

Learning differences

Has your teen received learning support or accommodations at school?

Check all that apply:

IEP or 504 plan

Academic or learning support services

Speech or language services

Attention or processing-related challenges

Ongoing struggles without a formal plan

No known learning concerns

Not sure

Other

Describe other support or accommodations your teen may be receiving:

Is your teen currently receiving support for these concerns?

Yes (therapy, school support, medical care, etc.)

Not sure

Safety concerns

Have you had any concerns about your teen’s safety?(Required)

(Based on what you have observed or been told)

Yes, in the past

Yes, currently

Prefer not to answer

Additional information

Is there anything else you’d like us to know about your teen or your goals for therapy?

Final Step: Confirm & Continue

Thank you for taking the first step toward supporting your teen’s mental health. A Breathable therapist will follow up with you directly to complete the intake process and obtain any required parental consent in accordance with your state’s laws.

Please review the below consents, and provide you and your teen’s contact information so that we can reach back out to you.

I agree to the Terms of Service and Privacy Policy.

Telehealth Consent(Required)

I consent to care via telehealth.

My First & Last Name:(Required)

First Last

My 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.

My Phone Number:

My Teen's First & Last Name:(Required)

First Last

My Teen's Email Address:

Enter Email Confirm Email

My Teen's 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.