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Inquiry Form
Thanks for reaching out!
*Please note that I do not have availability for new clients at this time.*
Please fill out this form to help determine availability and to help me provide appropriate referrals if necessary. I make every effort to respond within 5-7 business days.
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Email
*
Your email
Name:
*
Your answer
Phone number:
*
Your answer
How would you like to receive a response? Check your preference(s). Please note that I am unable to return phone calls in a timely manner. (By checking a box, you give permission for receiving that form of communication.)
Email
Text Message
For whom are you seeking counseling services? (Please note that I work individually with adults; I am unable to accommodate requests for couples, family, or children's counseling at this time.)
*
For myself
Other:
Required
What is your age?
Your answer
What are you hoping to address in counseling? (Please be as specific as possible to make sure that you receive appropriate recommendations for your needs.)
*
Your answer
Who recommended counseling?
*
Myself
Family member or friend
Another mental health provider
Doctor or medical professional
Internet or social media content about therapy or mental health
Other:
How did you hear about Undivided Soul Counseling?
*
Website (Google/Web search)
Word of mouth (friend, family member, co-worker, etc.)
Another professional
Insurance directory
Therapy Den
ISSTD
EMDRIA
Being Seen
Open Path
Other:
How would your sessions be covered? Check any that apply.
*
Husky / Medicaid / State insurance
Aetna
Anthem Blue Cross Blue Shield
Optum / United / Connecticare
Cigna / Evernorth
Carelon / Beacon Health Options / Value Options
Other insurance: will submit for out-of-network reimbursement (session fee $150 due at time of service)
Self-pay by credit card or check (session fee $150)
I have financial hardship and would like to inquire about Open Path sliding scale program (see website for details)
Other:
Required
What is your scheduling availability?
*
Flexible (morning, afternoon, or evenings on most days)
Weekday mornings (9-12)
Weekday afternoons (12-4)
Weekday evenings (4-6)
Weekends
Required
What is your preference for sessions?
Telehealth only (I have the required technology, Internet connect, and privacy for video sessions)
In-Person in Waterbury office
Mix of in-person and telehealth
No preference / any available
Clear selection
If I am unavailable to schedule with you, would you like to be provided with information about other possible providers?
*
Yes
No
Other:
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