Neuron and Rose Therapy Inquiry Questionnaire

Thank you for your online request to speak to one of our practitioners regarding therapy. We do have several providers with openings for new therapy participants (aka clients, or patients). You can read more about them here: https://www.neuronandrosepsychology.com/ourteam

We do offer these services remotely, for the most part (see individual bios for which therapists are taking in-person participants). Before we can schedule an initial consultation, or an initial intake, we have a few preliminary questions. Once you have answered them and we determine we are a good fit, we can proceed with either scheduling a no-cost consultation or moving forward with a initial intake (a full therapy session at your expense)! To help you determine which is the best next step, see a decision tree here. 

Some therapists may be open, for ones that are full, we do not have a waitlist at this time. Typically, we can get you started within a few weeks of the consult and/or completion of forms/invoice. However, this is subject to change at any time, as people are scheduled on a rolling, first-come, first-served basis. So if, for example, it takes several weeks for forms/the invoice to be completed, it is possible it may take longer to get scheduled. 

Technology can be glitchy at times, therefore, prior to submitting this form, you may:

  • consider emailing a copy of this form to yourself (by doing so, you acknowledge and accept the confidentiality risks associated with this). If you don't hear back within five business days, forward that copy of your answers to hello@neuronandrosepsychology.com to ensure that we've receive your submission! 
  • If you do not get a copy of your answers emailed to you, and you haven't heard from us in five business days, email us at hello@neuronandrosepsychology.com. If it turns out we do not have your submission, you'll be asked to complete the form again.
A note on language: as we work toward decolonizing therapy, we are working toward shifting language from "client" or "patient" to "therapy participant" per the book Decolonizing Therapy by Dr. Jennifer Mullan. 

Source: Dr Aimee Maxwell - Zenith Psychology (Ed Dev Psych)

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Email *
1. First and Last Name? *
2. What pronouns do you use? *
Required
3. Email Address: *
Best Phone Number to Reach You At?
4. Which state are you located in? *
5. If therapy participant is a minor or an adult with guardianship, please also provide first and last name of caregiver(s):
6. Therapy participant's date of birth: *
Those 65 or older: Please be advised, that we do not bill Medicare and ask participant's to sign this Medicare Opt-Out. MN. CA. 
7. What type of therapy are you seeking? *
At this time, our therapists are providing individual therapy. If you are interested in solely couples or family therapy, we will give you referrals. Please know that for minors, family involvement is either required, or expected, though, the focus during family therapy sessions are geared toward supporting you(parents) support your youth. 
Required

8. Currently, we are not contracted with any insurance companies. However you can contact your insurance company and see if they cover out-of-network providers, and if so, you may be able to submit what's called a "superbill," or a detailed receipt to your insurance to request reimbursement. 

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The superbill is something that we can have our system generate, as long as you communicate this to us. See resource here for more information. 
9. The cost of therapy ranges by each therapist, typically it's $175 to $250 per session, depending on who you are seeing. For example the lower end would be one of our doctoral students while the upper would be one of our psychologists or master's level clinicians. However, we do have a sliding scale for needs based aid. What is your per session budget for therapy?
 *
Here are some resources for therapy funds for BIPOC individuals. 
10. Do you identify as a Person of the Global Majority / or an individual that's Black, Indigenous or a Person of Color?
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