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New Client Request Form
This is a request is you are looking for psychotherapy treatment. It is important to make sure we are a good fit to work together. After this request I will set up a free 15 minute consultation. Filling our this form can help us pin point the best fit therapist for you!
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Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email Address
*
Your answer
What is your current schedule like? When would you ideally like to have your sessions scheduled?
Your answer
What type of Counseling are you looking for?
Individual Counseling
Family Counseling
Couples Counseling
Other:
Clear selection
Are you looking to receive EMDR therapy services?
Yes
No
I would like to know more about this
Clear selection
Do you have a specific therapist you would like to see?
Sherise Truman
Mireille Henry
Sherease Brown
MonaLisa Levy
Clear selection
What state do you currently live in?
Your answer
Phone Number
Your answer
History of Prior Treatments
Your answer
How did you learn about us?
Psychology Today
Google
Referral
Social Media
Other:
Clear selection
What are you ideally looking for?
Telehealth Sessions
In Person Sessions
Whatever is Available
Hybrid Sessions (Both Telehealth and In Person)
Clear selection
Will you be paying with insurance or out of pocket?
Insurance
Out of Pocket
Clear selection
If you are planning on using insurance, what current insurance do you have?
Your answer
Insurance Member ID Number
Your answer
Are you willing to be put on a wait list if needed?
Yes
No
Would like more information on this
Clear selection
Spirit Soul and Body Clinical Services use many modalities such as mindfulness, energy work as well as traditional therapy. Are you open to these concepts as a part of your treatment?
Not at all
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Yes Please!
Clear selection
Anything else you would like us to know?
Your answer
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