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New Client Intake

A gentle first step to share what’s going on before working together.

Beginning a new path takes profound courage. Please know that you can go entirely at your own pace, and you are welcome to share as much or as little as you feel comfortable with today. Your trust is sacred, and your information is held in the strictest confidence, except in rare instances where there are immediate concerns regarding your safety or the safety of others.

New Client Intake

This page is a gentle first step to share what’s going on before we begin working together.

Please move at your own pace and feel free to share as much or as little as you’re comfortable with. Your information is held in strict confidence, except in rare instances where there are immediate safety concerns for yourself or others.

Intake Form

Please fill out all required information below.

First name*

Last name*

Email address*

Phone number

Current Relationship Status

Do you still have hope to fix it? Why?

Length of Relationship

Why are you thinking about leaving?

Scale of 1 to 10 with 10 being ready to leave now, how ready are you to leave?

What is keeping you there?

Do you have any financial entanglements?

Yes

Do you feel safe ending the relationship?

Yes

Unsure

Any history of threats, controlling behavior or physical harm?

Yes

Unsure

By checking this box you agree

This is not therapy

This is strategic guidance

You are responsible for your own decisions

Pivot Point provides strategic guidance for relationship transitions. We do not provide legal, medical or mental health services

Safety Note: If you are in immediate danger, please reach out to emergency services or use a secure device to call the National Domestic Violence Hotline at 1.800.799.SAFE. Your safety is paramount.

By submitting this form, you gently consent to Pivot Point storing your information for the sole purpose of responding to your request for support.

Pivot Point

Accessibility Statement

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