Therapy Interest Form

Thank you for reaching out regarding therapy with me. Kindly complete the questions below. Typically, individuals on the waitlist can periodically check for any available openings. Additionally, I will notify you as soon as a spot becomes available. Please note that the waitlist timeframe is approximately 2-3 months, subject to your availability.

Sign in to Google to save your progress. Learn more
Email *
*
MM
/
DD
/
YYYY
Name (First, Last) *
Pronouns
Clear selection
Date of Birth *
MM
/
DD
/
YYYY
Email *
Phone Number *
Where do you currently reside? (please note that I only see Therapy Clients in the state of Massachusetts)
Clear selection
How did you find me?
Clear selection
Please provide a brief description about why you are seeking therapy.
What are you goals for therapy? What are you hoping improve through your experience in therapy?
Availability? Please note my hours are currently M-W from 10-5pm.
How do you plan to pay for therapy?
Clear selection
 Would you be interested in being on the waitlist if slots are no longer available? 
Clear selection
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Lorrie Bertrand LICSW. Report Abuse
Google Forms