Step 1 of 16

Age Check

What is your date of birth?(Required)

Month

Day

Year

Need support now? Resources for teens under 18

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

If you need support right now, you don’t have to wait. You can explore additional resources here:
View our full crisis resource page →

988 Suicide & Crisis Lifeline
Call or Text: 988
Crisis Text Line
Text HOME to 741741
Teen Line
Call: 1-800-852-8336 (evenings)
Text: TEEN to 839863
NAMI Teen & Young Adult HelpLine
Boys Town National Hotline
Call: 800-448-3000
Text: VOICE to 20121
The Trevor Project
Call: 1-866-488-7386
211 United Way
Dial 211
Emergency Services
If you are in immediate danger, call 911.

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:

Your Pronouns

Your pronouns (optional):

She/her

He/him

They/them

Use my name

Other

You don’t have to share this if you’re not comfortable. This helps us address you correctly.

What pronouns would you like us to use?

What brings you here?

What brings you here?(Required)

Feeling sad or down

Anxiety or constant worry

Stress or feeling overwhelmed

Anger or irritability

Trouble at school

Problems with friends or family

Trauma or past experiences

Identity or self-esteem concerns

Grief or loss

Other

Check all that apply:

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

Previous therapy

Have you ever been in therapy before?(Required)

Never

Briefly

For a few sessions

Over 10 sessions

School

Do you currently go to school?(Required)

Yes regularly

Yes, but I skip school sometimes

Current living situation

Where do you currently live?(Required)

At home with both parents

At home with one parent

Split custody with both parents

Other

Describe your current living situation:(Required)

Parent’s marital status

Are your parents going through a divorce?

Yes, currently

Yes, in the past

Diagnosed disorders

Have you ever been told by a doctor, therapist, school counselor, or psychologist that you have any of the following?

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

ADHD / ADD

Anxiety disorder

Depressive disorder

Bipolar disorder

Trauma-related disorder (PTSD)

Autism spectrum disorder

OCD

Borderline personality disorder

Eating disorder

I haven’t been diagnosed with anything

I’m not sure

Other diagnosis

List what other disorders you have been diagnosed with:

Learning differences

Have you ever been told you have a learning difference or receive extra help at school?

Dyslexia (reading)

Dyscalculia (math)

Dysgraphia (writing)

Processing or memory difficulties

Speech or language difficulties

ADHD-related learning challenges

IEP or 504 plan

I’ve struggled in school but don’t have a diagnosis

No learning difficulties

Not sure

Other

Check all that apply:

Describe other learning differences you may have:

Are you currently getting help or treatment for this/these?

Yes

Not sure

Self harm

Have you ever hurt yourself on purpose (cutting, burning, etc.)?(Required)

Yes

Prefer not to say

Finding your right fit

What kind of therapist would you feel most comfortable with?

Check any that matter to you:

Male

Female

Younger

Older

Shares similar background or values

LGBTQIA+ affirming therapist

No preference

What do you want your therapist to be like?

Check any that matter to you:

Calm

Direct

Funny

Serious

Very supportive

Gives advice

Mostly listens

How do you usually open up?

Check any that apply to you:

Talking

Writing

Art/creative stuff

I need time to trust

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.