Therapy Consultation Form
Please take a moment to complete this form. The following questions are used to ensure appropriate service.
**All therapy services are virtual unless noted otherwise.**
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Name: *
Age: *
Are you a Florida resident? *
Phone Number: (By providing your phone number you authorize contact for the purpose of receiving services.) *
Email: (By providing your email you authorize contact for the purpose of receiving services.) *
Select the therapy service are you presently seeking? *
What issue(s) would you like to address with therapy? *
Have you attended therapy before? If yes briefly explain *
Are you currently taking/prescribed psychotropic medication(s)? If yes, please list *
Are you currently suicidal?  National Suicide Prevention Helpline (Available 24/7) 1-800-273-8255. *
Required
If you are in CRISIS and need to speak with a mental health professional immediately, below are a few resources: National Suicide Prevention Hotline (dial 800-273-8255) or Text LIFE to 741741; 211 Local Community Resources Directory (dial 211 & listen to the prompt for the crisis counselor); If this is an EMERGENCY, please call 911 or go to your local emergency room.
Do you have a history of self harm or suicidal ideations? If yes, please explain. (If no, write N/A) *
Are you currently using substances or do you have a history of substance abuse? If Yes, please explain *
We do not accept health insurance. Documentation (Superbill) is available upon request should you wish to submit expenses to your insurance provider for reimbursement. Services could be considered as out-of-network benefits by your insurance provider. **Please check you insurance coverage carefully. *
Rates for therapy services are as follows: Individual-$120; Couples-$150; Family-$200. Please select a therapy service. *
How did you find us *
Please share appointment preferences.
Select any non clinical (therapy) service you wish to receive.
Which is your preferred social media platform? Select all that apply.
Please list any additional questions below.
Thank You for taking the first steps in your wellness journey. You will be contacted with further information to receive services.
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