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Get scheduled with us!

Once submitted, we'll reach out to you within 24 hours to schedule your initial consultation. (Just a quick "get-to-know-ya")

Want to skip all the box-filling?

Just give us a call or text!

If not, that's alright too, we'll talk to you soon either way!

Plainsman Therapy PLLC

Prospective Client Info & Contact Form

This form is designed to provide the practice with minimal background information for the clinician prior to the initial consult and IS NOT a replacement by any means for a professional evaluation. The completion and submission of this form does not guarantee services with Plainsman Therapy PLLC and is entirely voluntary—suitability for services is a mutual agreement between clinician and client, an agreement that typically takes place upon completion of the consultation period.

First name*

Last name*

Are you seeking therapy for:*

Yourself

My child/dependent

Other

Birthday of prospective client*

Month

Day

Year

Which best describes your current problem(s)*

I can't get past negative/upsetting events out of my mind

I struggle finding joy in life anymore

I feel like I've been wearing a mask that I can't take off

My relationships suffer from poor boundaries and a lack of communication

My fears and worries often lead me to feel out of control and overwhelmed

I have obsessive thoughts and/or compulsive behaviors that run my life

My day-to-day stress is wearing my down

I have an addiction(s) to substances, alcohol, or something else

Not quite it (describe)

How have you tried addressing this in the past?*

Previous therapy

Self-help books/podcasts

Talking with trusted friends/family

Various lifestyle changes

Ignoring it

Other

Who else have you told about your problem(s)*

Spouse/significant other

Friend(s)

Parent(s)

Past therapist

Other professional (PCP/Pastor/Case worker/Med provider)

Nobody

Other

If you no longer had to struggle with this problem, what would life look like? *

Which therapist would you like to connect with?*

Devan Rohrich, LPCC

Carrie Thompson Widmer, LCSW

Email*

Phone

Plainsman Therapy PLLC

Find Your Peace with Plainsman

701-419-1899

devan@plainsmantherapy.com

418 E Broadway Ave, STE 70,

Bismarck, ND 58501

No Surprises Act

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Once submitted, we'll reach out to you within 24 hours to schedule your initial consultation. (Just a quick "get-to-know-ya") ​ Want to skip all the box-filling? ​ Just give us a call or text! If not, that's alright too, we'll talk to you soon either way!

Plainsman Therapy PLLC

Prospective Client Info & Contact Form

Find Your Peace with Plainsman

Once submitted, we'll reach out to you within 24 hours to schedule your initial consultation. (Just a quick "get-to-know-ya")

Want to skip all the box-filling?

Just give us a call or text!

If not, that's alright too, we'll talk to you soon either way!