Consultation Request 
Please note, I can only see clients virtually who are in the State of PA, per my licensing restrictions.
I am close to the Maryland border and also offer customized intensives for those with longer commute. 

As of today, 3/7/24, I have VERY limited availability and do not have any evening or weekend sessions available. You can still complete the consultation form to connect, and be put waiting list, and/or I can give you additional resources in your area! 

I will be continuing to form groups throughout the summer to begin in Fall 2024, so please complete forms if you are interested in groups in Fall! (I offer Grief Groups, Trauma Groups, Shame, Understanding Emotions for Women, and will be starting a Skill-Building Compulsive Overeating Group soon!)

 (If you are in crisis, please call 911, go to your nearest emergency room, do not wait for a response for services!)  will reach out to get your free 15 minute consultation scheduled when I receive this form!
Sign in to Google to save your progress. Learn more
Email *
I am interested in:  *
Required
Have you read through my website & noticed that I do not accept any form of insurance as payment? 

You will pay out of pocket for services on your HSA or credit card (current fees as listed on website), and I will provide paperwork for you to contact your insurance company for possible out of network benefits, though that is between you and your insurance provider. 

If you are having symptoms that are interfering with your day-to-day functioning, I will recommend weekly sessions until those symptoms are better controlled. 

If it is not in your budget to do weekly sessions, it is best for you to see see someone in your budget then to be inconsistent with therapy.

It is best to meet 1x per week for at least 2-4 sessions for assessment, diagnosis, treatment plan development, and interventions to help.  
 *
Name (First & last) *
Age  *
Address *
Please tell me in brief, why you are seeking therapy? *
Do I have your permission to reach out to you in email to schedule a consultation call? *
Email Address  *
Are you having symptoms of mental health condition (if so, what kinds of symptoms), relationship issues, or need support with something (like betrayal, making a big decision, getting clarity, perfectionism, etc.) Do you have a mental health diagnosis from another provider? *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Trinity Wellness Group, LLC. Report Abuse
Google Forms