Emily Liu's Prospective Client Survey

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Thank you for your interest in working with me; I am currently unable to take on new clients. Feel free to visit the below websites for other therapists:

https://www.manhattanalternative.com/ (NYC-based, queer therapist directory)

https://asiansformentalhealth.com/ (Asian therapist directory)

https://www.asianmhc.org/ (Asian therapist directory)

http://therapyaccessproject.org/ (a nonprofit that assists queer and BIPOC individuals in obtaining mental health services)

Email *

What is your full legal name? *

What is your chosen name, if different from above?

What is your state of residence? (I can only see clients who reside in the state of New York.) *

What is your date of birth? *

YYYY

What is your race and/or ethnicity? *

Please describe your gender identity.

What are your pronouns?

What do you need help with? Check all that apply. *

Depression

Anxiety

Stress

Trauma

Family Issues

Relationship Issues

Racial/Ethnic Identity and/or Asian-American Experiences

Immigrant Families

LGBTQ Issues

Hearing Voices/Seeing Visions

Other:

Required

What is your availability for sessions? *

Morning (8am-12pm)

Afternoon (12pm-5pm)

Evening (5pm-8pm)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

How do you intend to pay for services? *

Out-of-network benefits

Out-of-pocket

Out-of-pocket using a sliding scale

Other:

Answer the following questions for yourself. Based on your responses, which strata best aligns with your current financial circumstances?

Sliding Scale Questionnaire

1. Are you and your family homeowners or landowners?

2. Have you attended private education institutions or do you have an advanced degree?

3. Are you bills or credit cards on auto-pay?

4. Can you easily access and afford healthcare or health insurance for you or your family members?

5. Do you have zero to no debt and/or do you have disposable income?

6. Do you have a safety net composed of “financially stable” or wealthy family and friends?

7. Do you have U.S. Citizenship?

8. Does your income only support you, and not other loved ones?

9. Have you or do you expect to inherit money or property?

10. Have you (or could you have) attended college and/or graduate school?

Send me a copy of my responses.

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