15 min. Consultation Request Form
This form is used to request a free 15 min. consultation with Mindful Therapy & Hypnosis. Once received, I will be in contact with you at my earliest convenience.
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Email *
Name and pronouns: *
How did you hear about Mindful Therapy & Hypnosis? *
Have you ever been in therapy before? If yes, when and what were you being seen for? *
What is your age? I work with clients age 14+. *
What service(s) of mine are you interested in? *
Required
Currently, I accept commercial insurance plans such as: Aetna, Cigna/Evernorth, Highmark/BCBS, UPMC, and United HealthCare/Optum. You are responsible for contacting your insurance company and ensuring that I am in-network with your specific plan prior to starting services. If a claim is returned to me unpaid from insurance, you are responsible for that cost. Sometimes claims can remain unpaid for weeks so we may not become aware of denials until you have been seen several times, so it is advised to make sure before beginning services to avoid a large unexpected bill. I am not contracted with any Medicaid/Medicare plans at this time. All insurance plans that I accept are commercial plans.

Also, please be aware that when using insurance: 1. All insurance companies require therapists to provide accurate diagnoses in order to pay for services, which will go on your medical record. 2. Insurance companies have the right to request and review therapy records. 3. Insurance companies have the right to limit the duration and frequency of therapy sessions, so scheduling will be based on medical necessity for those who choose to use their insurance benefits to pay for therapy.
 *
Required
How do you plan to pay for services? Below are both insurance and self-pay options.

Note: The insurance you select here will automatically be assumed as your primary insurance, assuming you have a secondary plan, which will be addressed in the next question.
 *
If you also have a secondary insurance plan: 

1. Please list the insurance carrier here 
2. Please confirm that you have filled out a Coordination of Benefits (COB) with both companies to ensure smooth claim processing. 
What are your concerns at this time? What are you hoping to work on/address in therapy? You can be brief.
 *
What are your goals for therapy? What are you hoping to gain from therapy? What do you want your life to look like as a result of our work together?
 *
Please check all boxes that apply to you presently OR in the past. If none apply, please select that box. 

These are not immediately disqualifying, but will need to be further discussed to see if I am an appropriate fit for your needs at this time.
 *
Required
When are you available to meet for regularly scheduled sessions? Check all times that apply: 

Listed below are all of my working hours, to gain an understanding of how aligned our schedules are. This is not an accurate representation of open time slots.
 *
Required
Please note here if specific days/times are most preferred.
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