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Phone Consultation Form
Preliminary questions to ensure appropriate service.
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* Indicates required question
DATE:
*
MM
/
DD
/
YYYY
Name:
*
Your answer
DOB:
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Which therapy service are you seeking?
Choose
Individual Therapy
Family Therapy
Couples Therapy
1 on 1 Wellness Coaching
Group therapy
Psychoeducational class
What issue(s) are seeking therapy to address
Your answer
Have you attended therapy before? If so give date
Your answer
How did you find us
T4BG
Google search
Referral
Website
Instagram/FB
BHenson
DRK Beauty Healing
Other/Unknown
Clear selection
Are you currently on any medication(s)? If yes, list
Your answer
Suicidal?
*
Choose
No
Yes, Thoughts only
Yes, Thoughts and plan
Yes, Attempt(s)
Suicidal? If yes when
*
Your answer
Appointment preference
*
Your answer
Payment agreed
*
regular rate
sliding scale
Free sessions
Submit
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