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New Client Request Form
This is a request is you are looking for psychotherapy treatment. It is important to make sure we are a good fit to work together. After this request I will set up a free 15 minute consultation. If I feel clinically someone else would be of better service to help you on your healing journey I will direct you in the right direction.
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Name
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Your answer
Date of Birth
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MM
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DD
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YYYY
Email
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Your answer
What state do your currently reside in?
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Your answer
Phone Number
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Your answer
Type of Counseling You Are Interested In
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Individual Counseling
Family Counseling
Couples Counseling
Other:
Referral Source, How did you find out about me?
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Your answer
Are you looking for ....
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Telehealth
In person
Either whatever is open
Briefly explain what you are looking for in a therapist and what you hope to get out of therapy.
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Your answer
Are you planning on paying out of pocket or insurance?
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Out of pocket
Insurance
If you are planning on using insurance what current insurance do you have?
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Your answer
Insurance ID number
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Your answer
Are you willing to be put on a wait list if needed?
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Yes
No help me find someone sooner
What is your current schedule like? When do you see your self being able to make appointments? My hours are between 8am and 2pm, weekdays would this work for you?
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Your answer
I consider myself a transpersonal holistic therapist, I use many modalities such as mindfulness, subconscious work, energy work as well as traditional therapy. Are you open to these concepts as a part of your treatment?
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Not at all
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Yes Please!
Anything else you would like me to know?
Your answer
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