Regulating Resolutions - New Client Inquiry Form
Please answer the following questions so Regulating Resolutions can determine if we will be able to effectively support you. If Regulating Resolutions doesn't believe we can provide effective therapy to you or if we do not have an open appointment, we will provide you with suggestions for other therapists.
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Email *
First name *
Last name *
Phone number (will be used in client portal account)
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Date of birth (will be used in client portal account and to confirm adult age) *
Preferred contact method
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Required
Regulating Resolutions is telehealth-only and does not currently provide in-person sessions. Are you okay with online sessions?
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Which psychotherapeutic service/treatment are you inquiring about? *
Required
In a few sentences: What would you like to address or work on in therapy? (Why are you seeking help now? What stressors do you have? What do you hope will be different by seeking help?) 
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For those interested in Accelerated Resolution Therapy (ART): What are the issues, concerns, and/or memories you are seeking ART to address?  Please take care of yourself with this response and only answer if you can do so without distress. (If not inquiring about ART, type N/A)
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For those interested in Accelerated Resolution Therapy (ART): Are you seeking adjunctive and/or supplemental treatment in addition to your ongoing psychotherapy with another therapist?
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How will you be paying for services?
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If you have insurance, what type of insurance do you have?
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Required
What is your availability for sessions?
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Required
How did you hear about Regulating Resolutions?
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Required
If referred by another mental health professional or other provider, who referred you?
Is there anything else you think I should know?
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