Consultation Request Form
I'd love to learn a little about you and what's bringing you to therapy. To be respectful of your time please provide the information requested below. You'll receive a follow-up email to access my calendar to schedule the appointment(if you haven't already). If I can't assist you I will provide you with some referrals.
Thank you! ~Tracy

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Email *
I'd love to know how you heard about me or Shades of Resilience Counseling. *
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First and Last Name: *
Phone Number: *
Date Of Birth

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Sex *
Race & Ethnicity *
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I accept ONLY the insurance providers listed below (please confirm benefits eligibility). For all other insurances, you may have out-of-network benefits, which means you will only have to pay your co-insurance for our sessions, instead of paying my full fee. I can help you verify if you have out-of-network benefits and how much your co-insurance would be. Select which option best applies to you *
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Private Pay Options.
Which service are you interested in? *
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What's your preferred mode of service? *
Do you require a specific day/time? Please explain below. *
Is this the first time you've considered therapy? *
In a few words, explain your reason(s) for seeking therapy. Why are you considering therapy now? *
If you know, what are you looking for in a therapist?
Would you consider group therapy in the future?
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Do you have any initial questions or comments?
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