Intake Form

Let's begin the conversation.

Submitting this form opens your email client to send your responses directly to Johnathan. He'll follow up within one business day.

Full Name *

Date of Birth *Phone *

Email *Address

Emergency Contact Name *Emergency Contact Phone *

Service Needed *Reason for SupportCurrent Support (therapist, group, mentor, etc.)GoalsSafety or Crisis ConcernsReferral Source

Direction3021 provides peer support, wellness education, WRAP planning, coaching, and group facilitation. Direction3021 does not provide therapy, clinical counseling, diagnosis, or emergency crisis services. If this is an emergency, call 911.

I have read the disclaimer above and consent to Direction3021 contacting me about my intake.