Therapy Intake | The Oasis Sanctuary

Confidentiality Notice. The information you provide is confidential and protected under HIPAA. It will only be used to assess fit and support your care. Please note that therapy services are only available to residents of states where Lady Jesaira Glover holds active licensure. If you are unsure, we will confirm eligibility before scheduling.

01 Your Contact Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

State of Residence * Therapy services are subject to state licensure. We will confirm availability after submission.

02 Emergency Contact

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

03 Clinical & Mental Health History

Have you previously been in therapy or counseling?

Yes No I'm not sure

If yes, what was helpful — or not helpful — in past therapy? This helps us understand your experience and serve you better.

Do you have any current or prior mental health diagnoses you'd like to share? This is optional. Sharing helps us prepare to support you well.

Are you currently taking any medications, including those prescribed for mental health?

Yes No Prefer not to say

04 Safety & Wellbeing

Are you currently experiencing any thoughts of harming yourself or others? *

No I have had passive thoughts, but I am not in immediate danger Yes — I need support now

If you selected "Yes — I need support now," please stop and call or text 988 immediately, or go to your nearest emergency room. This form is not monitored in real time.

05 What Brings You Here

What is bringing you to therapy at this time? * You do not need to have it all figured out. Share what feels true right now.

How long have you been experiencing this?

What would healing or support look like for you? There are no right answers — this is about your vision, not a clinical goal.

06 Session Preferences

Preferred session format

Virtual (telehealth) In-person (Atlanta, GA) Either works for me

Preferred days and times Select all that apply.

Weekday mornings Weekday afternoons Weekday evenings Saturday mornings Saturday afternoons Flexible / No preference

How did you hear about The Oasis Sanctuary?

Is there anything else you'd like us to know before we connect?

You will receive a confirmation email within 48 hours.
A member of our team will reach out to schedule your intake consultation.

Acknowledgment & Consent