Getting Started Inquiry form for Kimberly Louvin LCSW
This form will gather the necessary information for Kimberly Louvin LCSW to reach out to you regarding getting started in mental health therapy, scheduling an adult autism assessment, or helping you find a referral to a therapist who is able to help you.

Completion of this form does not guarantee services and is not an indication of establishment of a client-provider relationship. 

All information collected within this form is stored in a secure manner only accessible by Kimberly Louvin, LCSW.  
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About You
What is your full name? *
What is the Date of Birth of the person you are seeking services for? *
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What is your email address?  *
What is a phone number you can receive text messages at? If you do not want to receive communication via text regarding availability, please write N/A and all communication will be completed via email only. *
What state do you live in? *
Who are you seeking services for? *
Required
How did you hear about Unbroken Circles / Kimberly Louvin Therapy? 
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Have you participated in therapy before?
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Required
Are you interested in being on my wait list if my caseload is full? 
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Required
Do you consent to me sharing information about your request with Therapist Network Groups who may be able to offer referrals if I am not available for what you are seeking? 
Identifiable information such as your name and contact information will NOT be shared. I will receive information and send it back to you via email.
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About What You're Looking For
What type of service(s) or support are you looking for? (check all that apply) *
Required
What type of Mental Health Support Are You Seeking? (check all that apply, this does not lock you into anything specific)
What brings you to therapy and/or what are you seeking support addressing in your mental health?
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If you are seeking to use Health Insurance as a form of payment for Mental Health Therapy, please list your health insurance provider and Member ID (if available, no worries if not) for eligibility check.
What Timeframe of Day (in your time zone) are you Seeking to Schedule Appointments? (check all that apply)
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Required
What Day of the weeks are you available to Schedule Appointments in the timeframes above? (check all that apply and feel free to give details in the question after this)
If you have specific details regarding your availability noted above, please feel free to include that here
Is there anything specific you are looking for in a therapist/from therapy? Examples include: specific time frame availability, experience with specific modalities, experience working with clients in recovery from child abuse, ability to have varied appointment times vs. a fixed time slot, etc.
The answer to this questions helps me ensure I can offer you what you deserve, need, and check my availability appropriately. You are NOT required to answer this, however, it is helpful if I need to provide outside referrals due to limited availability.
Is there anything else you'd like to share?
Bonus Questions - these are helpful as I continue to expand online offerings
Which section of my website resonated most with you?
What questions would you like me to be sure to answer during our free consultation or via email?
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