Healing Out Lao'd, individual psychotherapy consultation intake form (CA residents only)

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hello and sabaidee!

Please fill out this form if you are interested in receiving more information about working with Rita Phetmixay, MA, LCSW (#109144) for 1x1 individual psychotherapy in virtual telehealth format. This initial intake is to understand your unique mental health needs & to ensure that both you and Rita are a good fit. Rita will connect with you within 3-5 business days to schedule a free 15 minute phone/video consultation.

find more info about Rita and their practice at www.healingoutlaod.org

Email *

Name & pronouns (i.e. she/her/they/them/ella, etc.) *

what problems have prompted you to seek mental health services? what areas in your life have been impacted due to your mental health challenges (i.e. school, work, interpersonal relationships, etc.)?

how long have you been feeling this way about this or these particular issue(s)/problem(s)?

0-2 weeks

more than one month, less than 3 months

between 3-6 months

at least 6 months

at least 1year

2 years or more

how do you imagine therapy would help you solve your unique mental health challenge? what do you desire in sessions? (i.e. coping with depression/anxiety, accessing joy, motivation, psycho-education on embodied healing, etc.) *

what's your level of urgency for addressing your mental health challenges? *

no rush, just shopping for therapists

I'm ready to start when you are!

have you sought or been in therapy before? how about any other forms of self-help? (coaching, yoga, self-help books, reiki, etc.) *

what are your expectations for therapy and having that 1x1 virtual support from a licensed therapist? *

what prompted you to reach out and see if Rita was a good fit to work with you? how did you find Rita or Healing Out Lao'd? *

I am aware that Rita Phetmixay's fees are $200 per 50 min individual telehealth sessions & does not accept in-network insurance or sliding scale options as valid forms of payment at this time. *

Yes

I would like to explore the option of "lunchtime" virtual therapy 25 minute sessions for $145.

Required

please add anything else that feels important to share about yourself:

Send me a copy of my responses.

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