New Client Screening Form

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Starting therapy is a big deal. I'm glad you made it here today and you're ready to get started. Please complete the form below and then schedule a free phone consultation.

Connectez-vous à Google pour enregistrer votre progression. En savoir plus

Excluding short trips, licensing laws require that you must be in Washington state while we are working together. *

I am located in Washington state

I work exclusively with adult women and womxn (18 and older). By “women,” I mean all people who have been socialized as girls and women, including cisgender women, transgender women, feminized bodies, and gender-nonconforming bodies.
*

That's me!

First and Last Name *

Your Pronouns *

Your Email *

Your Phone Number *

Which days and times are you generally available for weekly appointments? (These represent my working hours, not my current availability. When I email you, I'll let you know what appointment times are open.) *

Not available

9:00 AM

10:00 AM

11:00 AM

12:30 PM

1:00 PM

1:30 PM

2:00 PM

Tuesdays

Wednesdays

Thursdays

Insurance: Please check the applicable box *

I hope to use my out-of-network benefits. I understand that you will provide me with the appropriate documents and I submit them to my insurer.

I don't plan to use my insurance benefits or I don't have out-of-network benefits.

What is prompting you to seek therapy at this time?
*

I'm ready to do whatever it takes to get real and become the joyous, confident woman I was meant to be (or something like that).

I have therapy goals related to living better with a chronic illness or physical health condition.

I want to heal my relationship with food and/or my body.

Obligatoire

Briefly describe what you are you hoping to accomplish in therapy.
*

Do you have any questions I can answer straightaway?
*

After you have submitted the form, you will be prompted to schedule a free 15-minute phone consultation.

I look forward to connecting with you very soon! - Emily

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