Professional Consultation Inquiry Form
Thank you for reaching out for professional consultation! This form is designed so that I can get a bit more information on your consultation question or needs so that the time can be most effective for us. It allows me to do some pre-thinking, research of OARs/Codes of Ethics,  as well as gather resources for you. It is also important to me that you feel absolutely secure in your ability to be transparent in our conversation in regards to conflicts of interest. 

I'll reach out to you as soon as possible following submission of this form. 
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Name/Email/Practice Name, etc. *
How did you find out about me? 
What do you need to consult about? (No names needed)

For example, are your consultation questions related to clinical work/impasses/ruptures, ethical questions/dilemmas, or support with your own professional development? These are just a couple examples! No deep details needed/ broad strokes/overview is helpful. 
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Are there any conflicts of interest you are aware of? (No names needed at this time, just describe the nature of the potential conflict)

Examples of conflicts of interest: I already work with one of your employees for supervision, I've already consulted with a colleague also involved in the case, You are a group practice owner and are aware that I see your employee for consultation, etc. 

This doesn't rule out my ability to work with you, it just allows me to make effective decisions for both of us.
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How time sensitive is your request? 
What days/times are usually good for you to meet up? 
How would like to meet? 
Do you have any additional questions or concerns?
Submit
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