Consultation Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Hi there, thank you for your interest in working with me. I would like to get to know you a little better before we start this journey together. Please take some time to fill these questions out and I will reach back out to you through email on how we can move forward.

Please allow 2-4 business days for a response to your request, thank you for your patience.

If the possibility arises that I am unable to accept new clients or your needs may be beyond my training and expertise, I am happy to provide resources and referrals to altneratively qualified mental health profesionals that could better assist you.

Courtney Howell, LCSW

Blossom and Bloom Counseling, LLC

‪(706) 538-8336‬

First name *

Last name *

Email *

Phone number *

Are you using an insurance plan (if so, what insurance) or private pay? *

Briefly describe the issues you are seeking therapy for. *

Have you been to therapy before? *

Yes

Have you experienced thoughts of suicide or had any attempts within the last month? *

Yes

Have you experienced thoughts of hurting others within the last month? *

Yes

Do you have history of self-harm (ex: cutting) *

Yes

Have you ever experienced hearing voices or seeing things that other people do not? *

Yes

Have you ever stayed at a psychiatric hospital? *

Yes

Experienced significant issues with eating disorders, substance abuse, or gambling? *

Yes

Are you currently invovled in any legal or court matters that would require a mental health professional to engage or particiapte in? *

Yes

Have you ever recieved a diagnosis such as Bipolar Disorder, Borderline Personality Disorder, or Schizophrenia? *

Yes

If you answered yes to any of the previous questions, please provide a brief explenation. *

Sessions are telehealth only at this time. *

Yes, this works for me

I would prefer in person and understand recieving a referral to someone who provides this

How did you find this office

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Blossom and Bloom Counseling. Report Abuse

Forms