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Consultation Request Form
I'm looking forward to learning what's bringing you to therapy and discussing how I may be able to help you. To be respectful of your time please provide the information requested below. You'll receive a follow-up email giving you access to my calendar to schedule the appointment.
Thank you! ~Tracy
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Email
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Your email
*
Your answer
I'd love to know how you heard about me or Shades of Resilience Counseling.
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Referred by someone
Provider/Organization
Facebook
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Other:
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Date Of Birth
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Phone Number
Your answer
Developing rapport is vital in the client-counselor relationship. To achieve this they must be a good fit. Confirm you have reviewed the Shades of Resilience Counseling website (i.e. Bio, Fees, FAQs). www.shadesofresiliencecounseling.com
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Yes
Not yet but will before the appointment
Which service are you interested in?
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Individual Therapy (MUST RESIDE IN THE STATE OF TEXAS)
Group Therapy (MUST RESIDE IN THE STATE OF TEXAS)
Mindfulness Meditation Coaching (ANYONE/ANYWHERE)
Required
Is this the first time you've considered therapy?
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Yes
No
In a few words, explain your reason(s) for seeking therapy. Why are you considering therapy now?
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Your answer
In a few words, describe what you hope to achieve from therapy?
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Your answer
Would you consider group therapy in the future?
Yes
No
Maybe
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If you know, what are you looking for in a therapist?
Your answer
Do you have any initial questions or comments?
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Send me a copy of my responses.
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