JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Consultation for Counseling Services
Please complete and submit the following form for consideration for individual counseling. Your responses will be reviewed and you will be contacted in 24-48 hours (excluding weekends and holidays) via phone, if applicable, to discuss your counseling needs. During this brief phone conversation, you will have an opportunity to ask questions about working with me or the counseling process.
Submitting this form is not an agreement to receive counseling services; however, it is the first step in the process. If applicable, the next steps include a brief phone discussion about your counseling needs and scheduling your first session.
**๐๐ณ ๐๐ผ๐ ๐ฎ๐ฟ๐ฒ ๐ฐ๐๐ฟ๐ฟ๐ฒ๐ป๐๐น๐ ๐ถ๐ป ๐ฐ๐ฟ๐ถ๐๐ถ๐ ๐ฎ๐ป๐ฑ ๐ฒ๐ ๐ฝ๐ฒ๐ฟ๐ถ๐ฒ๐ป๐ฐ๐ถ๐ป๐ด ๐๐ต๐ผ๐๐ด๐ต๐๐ ๐ผ๐ณ ๐๐ฒ๐น๐ณ-๐ต๐ฎ๐ฟ๐บ, ๐ผ๐ฟ ๐ต๐ฎ๐๐ฒ ๐ฎ ๐ฝ๐น๐ฎ๐ป ๐ณ๐ผ๐ฟ ๐๐ฒ๐น๐ณ-๐ต๐ฎ๐ฟ๐บ, ๐ฝ๐น๐ฒ๐ฎ๐๐ฒ ๐ฐ๐ฎ๐น๐น ๐ต๐ญ๐ญ ๐ป๐ผ๐ ๐ผ๐ฟ ๐ด๐ผ ๐๐ผ ๐๐ต๐ฒ ๐ป๐ฒ๐ฎ๐ฟ๐ฒ๐๐ ๐ฒ๐บ๐ฒ๐ฟ๐ด๐ฒ๐ป๐ฐ๐ ๐ฟ๐ผ๐ผ๐บ ๐ณ๐ผ๐ฟ ๐ฎ๐๐๐ถ๐๐๐ฎ๐ป๐ฐ๐ฒ.**
Sign in to Google
to save your progress.
Learn more
* Indicates required question
What is your name? (
Please provide your first and last name.)
*
Your answer
What is your phone number? (
Please provide your phone number to receive a follow-up call in scheduling your first session, if applicable.)
*
Your answer
What is your email address?
*
Your answer
Are you at least 18 years old? (
You must be at least 18 years old for individual counseling services. If you are not at least 18 years old, please exit this form now.)
*
Yes
No
What is the city and state of your current residence?
(To receive services, you must reside in the state of Georgia or Alabama. If you do not currently reside in Georgia or Alabama, please exit this form now.)
*
Your answer
Are you able to meet virtually for counseling sessions?
(All counseling sessions are online and conducted via a secure and HIPAA compliant app.)
*
Yes
No
What has prompted you to reach out for counseling services?
*
Your answer
What symptoms or challenges are you experiencing at this time? Please check all that apply.
*
Depression
Anxiety
Grief and loss
Relationship Conflict
Life transitions (i.e., relocation, divorce, loss of employment, etc.)
Stress
Identity related concerns
Other:
Required
Have you previously received counseling? If so, when?
*
Your answer
Are you currently involved in any legal cases (i.e. divorce, lawsuit, custody case, Georgia Division of Children and Family Services case, etc.)?
*
Yes
No
If you are currently involved in a legal case, please identify the nature of the case.
*
Your answer
What is your availability to meet for counseling sessions?ย **
At this time, ONLY morning and early afternoon until 6 PM appointments on Monday's, Tuesdays, Wednesdays, and Fridays are available. Appointments after 6:00 p.m. are NOT available.
ย
**
*
Your answer
How do you plan to pay for counseling services? (Aetna, United Healthcare, Oscar Health, and Oxford are
ย the only accepted commercial insurance plans at this time.)
*
Self-Pay. I plan to pay for services out-of-pocket. I do not plan to use commercial insurance
Aetna
United Healthcare
Oscar Health
Oxford
Other:
If you plan to use insurance, do you agree to contact your insurance provider prior to your first appointment to learn what your financial responsibility will be for services?
Yes, I agree.
Yes, I agree; but, I need some guidance on this process.
Clear selection
How did you learn of my practice?
I was referred by a therapist or mental health clinician
I was referred by a friend or family member
Google/Internet search
Social media
Psychology Today
Other:
Clear selection
What is your availability for a brief phone call to discuss your counseling needs and schedule your first session, if applicable? Please be specific in providing days and times during the workweek when you are available.
*
Your answer
Would you like to share additional information not asked or addressed on this form? Is there anything else you would like me to know at this time?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
