New Client Consultation Request Form 
Thank you for interest in working with me. Let's get started!

PLEASE READ CAREFULLY.

You must be 18 years or older to complete this form. Submitting this form is NOT an agreement to begin treatment services. This page and website also are not monitored 24/7. If you are having a medical or mental health emergency, please call 911 or visit your local emergency room. For crisis and community resources, please visit my client resources page at here.

  1. Fill out this form in its entirety.
  2. Once completed, please schedule your consultation call here.

Your form will be reviewed within 24-48 business hours.  

I look forward to hearing from you!
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Email *
Today's Date *
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First Name *
Last Name *
Date of Birth *
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Age  *
Race/Ethnicity *
Gender *
Phone Number *
Email Address *
What kind of therapy are you looking for?
Clear selection
What issues would you like to discuss? *
Have you ever participated in therapy before? *
If you have participated in therapy, how long ago and why did it end?
How committed are you to participating in therapy? *
I am not ready.
I am ready.
How soon are you looking to begin therapy? *
What are the ideal times you prefer to schedule therapy sessions? Please select all that apply. *
What days of the week are best for you?
How do you plan to invest in therapy? *
Do you have health insurance?  *
If you have health insurance, who provides your coverage? *
How did you find me?  *
Are there any pending legal actions, court dates divorce proceedings or custody cases currently in progress?  *
Have you contemplated suicide in the last 6 months to 1 year? *
Have you had any recent hospitalizations for mental health services? *
Are you currently under a doctor's care and being prescribed any psychotropic medications? *
Consent to Contact *
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