JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
BOOKING an INITIAL CONSULT (INTEGRITY THERAPY)
Please fill this out and I will get back to you to book a free initial call of 20-30 mins to discern with you the best next steps.
* Indicates required question
Who is seeking to create positive change and grow through therapy?
Myself
My partner
My kid (s)
Other:
Clear selection
How MOTIVATED is this person to GROW and EVOLVE?
No desire, actually...
1
2
3
4
5
6
7
8
9
10
DO WHATEVER IT MAY TAKE!
Clear selection
What is your biggest HOPE and WISH for therapy?
Your answer
What is your biggest CONCERN (for you or the person you are inquiring for)?
Your answer
Do you understand the rates (see website) and/or about whether your insurance covers REGISTERED PSYCHOTHERAPISTS (RP) or not?
Yes -- it is covered. I checked!
Not covered but I am able to pay regardless.
Not sure -- will contact insurance co to check!
Other:
Clear selection
IF we both decide that it is a good fit and you (or the person you are seeking help for) is ready to change...
Would you prefer to...?
Come in PERSON for outdoor walks
Meet via phone (audio)
Meet via VIDEO (secure and private service)
Other:
Clear selection
WHEN would you be able to meet for consult and possibly our sessions?
NOT possible
DOABLE
FIRST CHOICE!
Weekday - early -- 7 - 9am
Weekday - mid morn. -- 9am - noon
Weekday - early aft. -- noon - 3pm
Weekday - late aft. -- 3 - 6pm
Weekday - eve - 7 - 9pm
NOT possible
DOABLE
FIRST CHOICE!
Weekday - early -- 7 - 9am
Weekday - mid morn. -- 9am - noon
Weekday - early aft. -- noon - 3pm
Weekday - late aft. -- 3 - 6pm
Weekday - eve - 7 - 9pm
Clear selection
If the options above would not work or are not preferred, please suggest when you would be available...
Your answer
Are you open and/or looking for other resources such as...
*
NOT needed
Maybe, tell me more
YES!
MEN's groups
Healthy communities
Body and wellness referrals
Martial Arts training
Parenting support
Serious Mental Health/Addiction support
NOT needed
Maybe, tell me more
YES!
MEN's groups
Healthy communities
Body and wellness referrals
Martial Arts training
Parenting support
Serious Mental Health/Addiction support
To be able to REPLY to your request, please type in your FIRST name + best EMAIL ADDRESS please:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Powerful And Loving (PAL).
Report Abuse
Forms
