Therapy with Nanyonjo - Consultation Interest Form
My work as a therapist is rooted in abolition, disability justice, queer/trans* liberation and anti-white supremacy. So, I prioritize working with BIPOC especially queer & trans* folx and folx with chronic illnesses. In order to have more space than a 15min consultation allows, this form is an opportunity to share about yourself including your interest in therapy. It also allows me to get a snapshot of our potential compatibility as therapist and client(s). After the form is complete, I will reach out to schedule a meeting with you.
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Email *
Relationship to Potential Client *
First Name (s) *
Phone *
Where in California are you located? *
Pronouns/Gender Identity
Sexual Identity
Racial Identity *
Required
Age(s) *
Have you been in therapy before? *
What type of therapy are you interested in? *
Required
In your own words, describe the current issues that you’re struggling with? (Examples: depression, anxiety, stress, substance misuse, trauma, racism and unhealthy relationship or family dynamics)
 *
What approaches are you interested in working with? (Go to my website & follow the links for further information about each type of therapy) 
What is your availability? (My current spots are biweekly only with the rates of  $75-100 for individual therapy and $150-200 for partnership(s) or family therapy. I don’t take insurance but do provide superbills.) *
Due to having a chronic illness that results in pain and/or fatigue flare ups, I might have to occasionally reschedule our session. Are you okay with that? *
Any additional information that you would like to share?
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