Therapy Interest Form

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If you are interested in engaging in therapy services with Empieza Aquí Counseling, please complete this form and we will get back to you as soon as possible.

We offer telehealth services to clients physically located in Arizona at the time of session. Our current rate for new clients is $145 for 45 minute therapy sessions. We do NOT accept insurance. There is no extra charge for the intake appointment.

We currently only work with adults who are 18 years and older and are only providing services for individuals (no couples or family therapy). All sessions are provided as telehealth appointments.

Please note that completing this form does not make you a client of Empieza Aquí Counseling.

For QTBIPOC Adults interested in sliding fee availability, see question at the end of form

Email *

Name: *

Age: *

Phone Number: *

Would you be physically located in Arizona at the time of services *

Yes

Other:

How often are you wanting to meet with your therapist? *

Weekly

Every other week

I'm not sure and I'd love to figure this out with my therapist

Required

What are you hoping to address in therapy? (ex: anxiety, trauma, grief, depression) *

Have you ever received a mental health diagnosis? If so, what? *

Any overuse/abuse/dependence on alcohol, drugs, or any substance? If so, please describe: *

Any experience with hallucinations or delusions? If so, please describe: *

How are you hoping life will look or feel differently a year from now by engaging in therapy? *

How passionate are you about seeing the above answer come true? *

Not at all passionate

The most passionate

If we hop on a call together and both determine that we are a good fit to work together, are you ready to fully invest (financially, mentally, and time) into yourself and our work together? *

Yes

Other:

We only see clients Monday - Wednesday with current availability being midday. What is your availability? Days/times you're typically free to meet *

Our current session fee is $145 for 45 minute sessions via telehealth. *

I acknowledge the above information and am in agreement with this.

Other:

What made you interested in working with Empieza Aquí Counseling? *

How did you find out about us? *

Any additional info you would like to share in this interest form:

If you are a QTBIPOC Adult interested in the weekly/biweekly Wednesday at 2pm sliding fee availability, please state reason for interest and financial need:

If this is in response to the offer for a couple “pay what you can” sessions for adult students struggling with their experiences at Pro-Palestinian encampments and rallies, please tell me a bit about what you hope to accomplish in those sessions:

Next steps:

Please note that completing this form does not make you a client of Empieza Aquí Counseling.

We will contact you to let you know if we may be a good match for you based on your responses to this form, or if there are referrals we may be able to provide to better meet your needs.

We appreciate your interest in working with Empieza Aquí Counseling!

A copy of your responses will be emailed to the address you provided.

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