Client Inquiry Questionnaire
Thank you for your interest in our services. To help us better support you, please complete the following questionnaire. Once we receive your response, one of our staff will endeavor to be in touch within 72-hours Monday through Friday to clarify details or to arrange a complimentary call with one of our clinicians. The call is to see if you have additional questions and to determine if you all are a good fit to work together at this time.

Please note that, while we do not accept insurance, we will happily provide you with a superbill for potential reimbursement from your insurance provider (confirm your eligibility for this option directly with your provider).

Don't hesitate to contact info@wildernesstherapyinstitute.com with any questions or concerns in the meantime. All of your information is secure and confidential within our organization.

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Email *
Phone number
Please let us know your preferred method of contact (email or phone) and if we have your permission to leave a voicemail (if applicable). *
Name *
Please share the pronouns that you or the person you are inquiring about use (e.g. she/her/hers or they/them/their or xe/xem/xyr):
What are you seeking support for at this time?
What about our services calls to you (why did you reach out to us)?
What is your age or the age of the person you are inquiring about?
Are there any significant circumstances you want to let us know about that may be impacting your current situation (addiction, abuse, current health situation, eating disorder, court cases, other big occurrences)?
Do you have Medicaid? *
Where are you located?
Do you have questions about our institute or practitioners?
Is there anything else you'd like us to know as we match you with a practitioner?
How did you hear about us?
We have varying levels of fees available depending on the practitioner and their qualifications and experience (ranging from $180 to $50 per session). Please let us know if that strongly impacts who you work with.
What is your general availability for scheduling? Please let us know if you have specific requirements.
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