Wait List Confirmation Form

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This form will gather the necessary information for Kimberly Louvin LCSW to reach out to you regarding getting started in mental health therapy, scheduling an adult autism assessment, or helping you find a referral to a therapist who is able to help you.

Completion of this form does not guarantee services and is not an indication of establishment of a client-provider relationship.

All information collected within this form is stored in a secure manner only accessible by Kimberly Louvin, LCSW.

By checking this box, you are acknowledging that you understand that being on the Waiting List is NOT a confirmation of a client - therapist relationship, but is confirmation that you'd like to receive updates when client spaces are available to consider beginning a client-therapist relationship *

Yes, I understand being on the wait list is not being a client

No, I don't understand, please contact me to explain

Other:

Required

This form will be utilized to confirm continued desire to remain on my waiting list. Please check which box applies to you. *

This is my first time completing this form, I am new to the wait list

I have been on the wait list and would like to remain on the wait list

I would like to be removed from the wait list.

Other:

Required

What is your Full Name? *

What is your birthday? *

YYYY

What is the best email for you? *

What is a phone number you can receive text messages at? If you do not want to receive communication via text regarding availability, please write N/A and all communication will be completed via email only.

What State Do you Live in / Will You Be Completing Therapy From (check all that apply) *

Oregon

Washington

Tennessee

Florida

I Live Outside the USA

Required

What Timeframe of Day (in your time zone) are you Seeking to Schedule Appointments? (check all that apply)
*

Morning (9am-11am)

Early Afternoon (11:01am-2pm)

Mid Afternoon (2:01-5pm)

Early Evening (5:01pm-7pm)

Late Evening (7:01pm-9pm)

Other:

Required

Which day of the week are you seeking or open to therapy appointments in the time frames above? (please feel free to be more descriptive in the 'other' box as needed. I offer services Monday-Thursday depending upon availability)

Monday

Tuesday

Wednesday

Thursday

What type of Mental Health Support Are You Seeking? (check all that apply, this does not lock you into anything specific)

Short Term Therapy (2-6 Months / 8-24 sessions)

Ongoing Therapy (seeking ongoing support, typically weekly at first, then biweekly by 6 months in, and monthly appointments as long as beneficial to the client)

Assessment / Diagnosis Integration Focused Therapy (1-2 Months / 4-8 sessions)

Group Therapy (Groups meet Weekly at First and Monthly by decision of the group, 13 members max))

Mental Health Workshops/Webinars about Late Diagnosed Autism and/or other Mental Health Topics

Other:

Check any of these that apply so that I can be sure to contact you about your specific support needs:

Finding a Therapist in General is my priority, I'd really like your help finding me anyone with current openings, even if it's not you.

I don't know what I'm looking for yet, but keep me on this waiting list and I will let you know when I decide

I'm utilizing my health insurance and it expires soon, I'm really hoping to find a therapist who can see me while I still have health insurance.

Other:

If you are looking for referrals for a therapist with openings because I am currently full, please share a sentence or two about what you are seeking and I will post this to a therapist networking group and email you referrals.

Feel free to include anything specific you are seeking and I will copy/paste that information and share with you contact info that is given to me for other therapists with current openings.

If you are looking to use your Health Insurance Benefits to cover some of the cost of Therapy, please list your health insurance company and insurance info.

If you are utilizing health insurance benefits that have an expiration date you're aware of, please feel free to include that information here.

Is there anything else you'd like to share? If you completed the "getting started" form, has anything changed since that time?
*

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