New Client Consultation Form
In order to make the best use of your time, please answer the questions below to determine if it makes sense to move forward with an appointment. Please email me at: Jennifer@truealignmentcounseling.com if you have any questions! This form is secure and confidential, and is only seen by you and me. Completing this form does not obligate you to enter therapy. 
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Last Name, First Name *
So that I know how to respectfully speak to you, please check the box(es) that most closely represent your gender pronouns (note that this is not an exhaustive list): *
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Today's Date *
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How did you hear about me? (i.e. my website, google, friend/family, another therapist, mental health match, psychology today, etc)
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State of Residence *
Time Zone *
Contact Number (with area code) *
If I do not answer, I consent to a voicemail being left at this number. *
What is your primary email address? *
I understand that email is necessary for the purposes of scheduling/logistics, and I consent to this. *
I understand that Jennifer Livingstone is licensed in North Carolina, South Carolina, Vermont, and Florida. I understand that I, or anyone else who participates in my sessions, must be physically located in one of these states for all telehealth sessions. *
I understand that Jennifer Livingstone only provides telehealth counseling, and does not offer in-person visits. *
I understand that Jennifer Livingstone’s hours are as follows: Monday 8AM-3PM, Tuesday 8AM-3PM, Thursday 9AM-4PM & Friday 8AM-12PM. My availability for therapy works with this schedule.
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I am at least 18 years old, and understand that anyone who participates in my therapy sessions must also be at least 18 years old. *
I require a card placed on file for payment. I do not accept cash, check, venmo, paypal, or any other method of payment.
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I have a smartphone that can accept text messages. *
I have a private email address that can be used to receive links to Google Meet sessions. *
I understand that Jennifer Livingstone uses Google Meet as a secure, HIPAA-compliant video platform for telehealth sessions. I am willing/able to use this platform. *
I have a private space where I can meet for telehealth sessions. *
I understand that while I can have a therapy session in a parked car, I cannot be driving while having a therapy session.
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Please choose which funding source you will be using for therapy: *
Please note the following caveats of using insurance: 1) All insurance companies require therapists to give clients a mental health and/or substance abuse diagnosis in order to pay for treatment 2)Insurance companies have the right to request and review therapy records 3)Insurance companies have the right to limit the duration and frequency of therapy sessions. *
If you have insurance, but are choosing to opt out and be a Private Pay client (paying the private pay rate out of pocket instead of using insurance) please list which type of insurance you have (put n/a if not applicable).
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Are you involved in a legal situation for which you are seeking a therapist’s involvement (court appearance, letters, diagnosis,etc)?
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I am seeking counseling at the following frequency: *
Please list the days/times that you are available for counseling sessions: *
Please briefly describe the concerns/issues for which you are seeking support: *
Please select one of the below: *
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