New Client Questionnaire - Join My Waitlist
Hi! The answers you provide on this form will give me a better idea of what you are needing from therapy at this time & if I will be a good fit for you. 

Once you fill out this questionnaire I'll e-mail you within two business days to get in touch & give an estimate about when my schedule will open up. I'm excited to get to know you! 
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First & Last Name: *
Preferred Pronouns: *
E-mail Address: *
Phone Number: *
Date of Birth: *
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Where do you live? City, state? 

I only provide counseling services to Texas & Utah residents. If you live outside of Texas or Utah, I will not be responding to your inquiry. 
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How did you hear about me? *
What is bringing you to therapy at this time? What are you hoping to address or explore? Please be as detailed as possible. *
What goals do you have for therapy? *
Have you worked with a therapist before? If so, when did you work with them and what was your experience like? 
 *
Do you take any medications for your mental health? If so, what medications & what do you take them for? *
Have you previously received any diagnoses? If so, what are they? *
Which of the following have you experienced? *
I have experienced in the past
I am currently experiencing
I have not experienced
Suicidal ideation (thoughts, plans, or attempts to kill myself)
Homicidal ideation (thoughts, plans, or attempts to kill someone else)
Self-harm (intentionally cause physical harm to oneself)
Abuse (physical, sexual, emotional, verbal, financial)
Substance abuse issues
Eating disorder or disordered eating behaviors (restrict food intake, excessively exercise, self-induced vomiting, hide food, frequently eat past the feeling of fullness, etc.)
Hear voices inside my head that others cannot hear and/or see things that are not there
Panic attacks or anxiety attacks
Periods of daily sadness lasting more than two weeks
Which of the following are you looking to address in therapy?  *
Required
Please be aware that amongst other presenting mental health concerns, I do not specialize in or see clients experiencing suicidal ideation, intrusive thoughts or self-harming behaviors. I also do not work with clients with personality disorders, eating disorders, or substance use disorders. If you are experiencing any of these issues, please indicate below. If I am able to, I will try to help you find a clinician who can best help you with these concerns. (If you are not experiencing any of this issues, you can leave this response blank). *
Required
What type of therapy experience do you prefer? *
Required
Which of my offerings/modalities are you interested in? (You can read more about each of these services on my website). *
Required
I currently see clients in-person Monday - Wednesday. I see clients virtually on Thursday. 

Please mark any possible availability for sessions below. My current openings are limited, you can view them on my calendar. If you don't see a slot that works for you but are interested in working with me, feel free to still mark your availability below & I'll see if we can make our schedules work.
Monday (in-person)
Tuesday (in-person)
Wednesday (in-person)
Thursday (virtual)
10:00am
11:00am
12:00pm
1:00pm
2:00pm
3:00pm
What is your desired frequency for sessions? 

I do not currently take new clients who wish to be seen less frequently than every-other week. After we work together for some time, we may decrease your frequency to an "as-needed" or "monthly maintenance" frequency.
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The following information is a brief overview of my therapeutic approach (you can read more on my website):

1. We will be exploring your past relationships & experiences to understand your current patterns. If you do not want to explore your past, I am not the therapist for you.

2. We will focus on emotional processing by helping you to identify, understand & feel your emotions. If you do not want to focus on your emotions, I am not the therapist for you.

3. We will be collaborating together: I do not give answers or advice. While I am the mental health professional, you are the expert on your life who will be guiding me as we understand your experiences. Because of this, you will have control in the room; each week, I will ask you what you want to focus on in our sessions. If you are looking for a therapist who tells you what you need to process & takes charge, I am not the therapist for you.

4. We will be engaging in a long-term process of exploration & healing. While we will work to alleviate stressors in the short-term, the process won't be a quick fix; it will take time. If you are looking to receive a list of tools & ideas for quick fixes, I am not the therapist for you.

Do you have any questions or concerns regarding my approach? (If my approach doesn't fit with you, that's okay! There are so many different approaches & I encourage you to find a therapist that best fits with your needs).
 *
Required
The following information explains some of my policies regarding payment: 

My rate is $125 per 50-minute session. 

I do not accept insurance. You will be responsible for the entire session fee if you cancel less than 24 hours prior to your scheduled session (72 hours for Monday appointments).

Before our first session I'll send you forms to enter your credit card information. I'll securely store those payment details & on the morning of each session, a charge will be made for the full payment of your session.
Do you have any questions or concerns regarding payment?
 *
Required
What else would you like me to know? Do you have any questions for me? *
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