Consultation Request

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Thank you for your interest in working with me. I would be happy to explore the possibility of us working together and would like to get to know you a little better. Please answer each question below. I will then provide some options on how we can move forward via email.

In the event that your needs are beyond my expertise, I am glad to offer you referrals to other qualified mental health professionals.

Briana Farlow, LCSW

Courageous Counseling and Consultation, LLC

First name *

Last name *

Email *

Phone number *

Do you live in Georgia? *

Yes

No - I understand I will receive a referral. Courageous Counseling can only serve clients who live in Georgia.

Sessions are available Monday-Thursday 9am-4pm. *

This works for me.

I need availability after 4pm and understand I will receive a referral. Courageous Counseling does not have evening or weekend availability.

Sessions are telehealth (virtual) only.

A limited number of in-person appointments will be available starting in June.

This works for me.

I want in-person sessions only and understand I will receive a referral.

Please select the types of issues and/or services that you are interested in.

Trauma or PTSD

Anxiety

Depression

Relationship concerns (romantic or platonic)

Life transitions related to: college/graduate school, dating and breakups, work stress, chronic health concerns, grief and loss

I am interested in traditional talk therapy (1-hour appointments).

I am interested in starting EMDR (1-hour appointments).

I am interested in booking a 3- or 6-hour EMDR intensive.

Other:

Required

What are your goals for therapy?

Other reflection questions: What are you hoping to gain from therapy? What do you want your life to look like as a result of our work together?

What is your current health insurance plan?

Please note that if you do not have one of the plans listed below, your services will be self pay.

I am not in-network with Medicare Advantage Plans.

EMDR intensives are self-pay.

United Healthcare

UMR

Aetna

Oscar

Oxford

Self Pay - $160

Office and/or person who referred you?
*

Please answer the following questions with “Yes or No”.

In the past month, have you experienced:

Thoughts, plans, or attempts of suicide?
*

Yes

Thoughts of hurting others?
*

Yes

Issues related to self-harm (ex: cutting)?
*

Yes

Hearing voices or seeing things other people do not?
*

Yes

An inability to control your behavior when emotional?
*

Yes

Please provide a brief explanation to any questions marked "yes." *

Please answer the following questions with “Yes or No”.

Have you ever in your lifetime:

Experienced severe suicidal thoughts?
*

Yes

Attempted suicide?
*

Yes

Experienced issues with self-harm?
*

Yes

Received a diagnosis such as schizophrenia, bipolar disorder, borderline personality disorder, or autism?
*

Yes

Stayed in a psychiatric hospital?
*

Yes

Experienced significant issues with eating disorders OR substance abuse?
*

Yes

Are you currently involved in any legal matters that would require a mental health professional to participate in?
*

Yes

Do you need any types of forms completed in the near future, such as applying for medical leave from work (FMLA) or disability (SSDI)?
*

Yes

Please provide a brief explanation to any questions marked "yes."
*

Do you have any initial questions or comments?

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