Client Interest Form/Waiting List
Thank you for reaching out to Therapy is my J.A.M., LLC.
Please take a few minutes to tell me a bit about yourself so that I can learn about your needs, and how best to serve you.

For the sake of my self care and delivering the best care to my clients, I am at capacity, and no longer accepting new clients at this time. If you would like to be added to the wait list, please provide your information below. I will be in touch once my schedule permits. Thank you for your understanding and patience.
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What is today's date? *
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May I have your first and last name? *
What is your date of birth? *
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What is the best email to send documents and communication to? *
What is the best phone number to reach you? *
Are you a resident of Maryland or Washington D.C.? (I am only licensed to see clients in these two areas) *
Which therapy services are you interested in? (ONLY BCBS & Cigna Insurance is accepted) *
If you are interested in Couples Therapy, what is your partner's first and last name?
If you are interested in Couples Therapy, what is your partner's email address?
Are you currently struggling with any of the issues below? *
Required
Do you currently have any thoughts or desire to harm yourself or someone else? *
Do you have any history of suicide attempts or suicidal ideation in the past? *
What has caused you to seek therapy at this time? *
What are you hoping to gain from therapy sessions? *
What days and times would be best for regular appointments?
11 a.m. - 1 p.m.
1 p.m. - 4p.m.
4 p.m. - 7 p.m.
Monday
Tuesday
Wednesday
Thursday
Would you like a 15 minute intro call? (Optional) *
How did you hear about my services?
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