Prospective Client Interest Form

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Thank you for your interest in working together! This step allows me to get more information from you as well as provide some information about my practice so we can assess whether I'll be a good fit for your needs.

Name *

Which state would you be physically located in for our sessions? *

Phone Number *

Primary Email *

Age *

Please share a few sentences on why you are seeking counseling at this time and what your goals would be in our work together. *

Please check any relevant areas of concern, both current and past. *

Mood (depression, bipolar, mania, dysthymia, etc)

Anxiety (generalized anxiety, social phobia, etc)

Eating Disorder (anorexia, bulimia, ARFID, binge eating, etc)

Trauma/Dissociation

ADHD

Personality Disorder (borderline, narcissism, obsessive-compulsive, avoidant, etc)

Obsessive-Compulsive and Related Disorders (OCD, body dysmorphia, skin picking, etc)

Substance Use

Other:

Required

Which E-Course did you purchase? *

CBT and Eating Disorders

Emotion Focused Family Therapy

Keep Calm (Perfectionism, Worry and Panic)

None

Other:

If we agree together that we will likely be a good fit for counseling, you understand the following:

*Sessions are held virtually via Zoom

*Some Aetna and United/Optum plans are accepted via Alma platform for clients able to commit to weekly or biweekly sessions and that the full fee is still charged for any cancellations with less than 24 hours notice.

* For all others, Private pay rates are $175 for 45 min, $200 for 60 min, etc, and that the full fee is charged for any cancellations with less than 24 hours notice.

Yes, I understand.

Other:

Will you be planning to use Aetna or United/Optum plan benefits for our sessions? *

Yes

No, I will pay privately (Superbills can be provided if you plan to submit your own claims for out of network)

I understand that Meredith does not communicate via text and outside of session time can primarily be reached via email. *

Yes, I understand.

Other:

Please include any questions you have for me and I will do my best to respond via email within 1-2 business days.

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