Talk Therapy Consultation Request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

I'm so glad you're interested in talk therapy! Please answer the following questions, and I'll reach out to you in a day or so to set up a time for us to speak.

First Name *

Last Name *

E-mail address *

Phone number *

What kind of therapy are you interested in? *

Individual Therapy

Relationship Therapy

Other:

What state do you live in? (I am licensed in New York, so I unfortunately cannot see you if you live in another state) *

In brief, what brings you to therapy? *

How would you like to pay for therapy? *

Self pay

Out of network benefits

Other:

My sliding scale is based on an anti-oppressive rate structure. Please answer the following questions to determine your rate. (Adapted from the Anti-Oppression Resource & Training Alliance, and Kenya Crawford, LCSW)

1. Are you and your family homeowners or landowners? (This question does not apply to those who are Native or Indigenous)

2. Have you attended private education institutions or do you have a post-graduate degree?

3. Are you able to make minimum payments on bills or credit cards?

4. Have you been able to easily access and afford health insurance for yourself and your family members?

5. Do you have little to no debt and/or do you have disposable income?

6. Do you have a safety net composed of “financially stable” or wealthy family and friends?

7. Do you have U.S. Citizenship?

8. Does your income only support you, and not other loved ones?

9. Have you or do you expect to inherit money or property?

10. Do you live (fully or partially) off unearned income? (such as a trust fund, dividends, interest, rental income from investment property, or support from family)

Redistribution: Yes to 7-10 questions -- individual, $225; relationship, $250

Full Cost: Yes to 5-7 questions -- individual, $200; relationship, $225

Sustain: Yes to 3-5 questions -- individual, $175; Relationship, $200

Solidarity: Yes to 1-3 questions -- individual, $150; Relationship, $175

Support: Yes to 0 questions -- Individual, $100-150; Relationship, $125-175

Other:

When are you available for sessions? (Monday-Friday) *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of grey perry healing. Report Abuse

Forms