Karen Lau, LCSW - Therapy Inquiry Form
I am glad to hear from you as you are taking the next step to attend to your well-being. 

Please fill out the following and I will be reaching out to you to schedule or provide a consultation.

I'm only licensed as a therapist in California. Please only submit an inquiry for therapy if you are physically located in California. 
Sign in to Google to save your progress. Learn more
Please enter today's date. *
MM
/
DD
/
YYYY
Please provide the email address and your first name which you would like me to use to communicate with you.

(Please check your spam box in the following days, as I will be writing to you to follow-up. My email may land in your junk mail box as it is new in your contact list.)
 *
What is the phone number you'll like for me to call for our consultation? *
Can I leave a message on your voice mail at the above number, if you do not pick up? *
Are you seeking in-person or video sessions? *
Can you please provide short general highlights on what you'll like to work on? And are you are looking for anything specific in a therapist as you seek to get therapy?  *
Have you done therapy in the past? If yes, please let me know what you may be looking for now that may be similar or different from your past therapy experience? If no, you can just note "none" here.  *
Are you currently dealing with pressing or acute symptoms at this time (such as panic episodes, self harm behavior, active suicidal plans, and/or active thoughts of hurting others)? Please provide information here. 

If there are urgent mental health symptoms and/or emergencies, please do not wait for my reply with the form submission. Please head immediately to the emergency room closest to you. This form is not meant for urgent crisis interventions.
 *
Once we have the consultation call and there are no concerns with fit, will you be ready to schedule an appointment for the following week if there's immediate availability?
 
What potential obstacles might be in the way before you are ready to schedule an appointment?
 *
How often would you like therapy? I only take clients who want to be  seen on weekly or alternate week basis as part of standard of care practice.  *
Required
Do you foresee any major gaps of more than 2 weeks in your upcoming schedule once you start therapy? If yes, please note estimation of how long and when. If not, just note "n/a" here. *
How long do you wish to be in therapy? *
What days and time of the week is best for you to have therapy? *
Did someone refer you? Or did you find me through a directory? Please let me know. *
In terms of fee, are you planning to use: *
Required
Anything else or if you have questions, please do share it here. *
Thank you for taking time to complete this inquiry form. I look forward to meeting and working with you. I will respond usually within 2-3 business days unless I am out of the office. 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Karen Lau, LCSW.

Does this form look suspicious? Report

Google Forms