Breaking Illusions Counseling

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Consultation Form

Email *

Hi there, what is your name? *

What is your email? This is for confirmation and basic contact.

What is your phone number? This is optional if you chose to be contacted this way.

How would you like to be contacted? *

Phone

Have you seen a therapist before? If so, what was your experience?
*

What are you needing support with?

Please share any hesitations or questions you might have about therapy.
*

What are your therapy goals for the next 3-6 months?

What are you currently struggling with when it comes to reaching those goals on your own?

What have you done in the past or are currently doing on your own to work through these struggles?

Why is NOW the time that you’re ready to start working through these challenges?

Are you prepared to make an investment in yourself to see your goals become reality? Counseling services start at $175 for the initial intake fee and ongoing services range from $50 for a 20 minute session to $150 for your standard session. At this time, are you ready to invest in yourself, not only financially, but also invest time and energy to make this work?

Yes, I am ready to get started!

I have a few questions that I would like to talk through but if it's a good fit then absolutely.

No, I am not ready at this time.

If it’s a good fit and you choose to move forward with services, what is your preferred payment method?

Private Pay

Blue Cross/Blue Shield Insurance

Medicaid Insurance

Other

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