Initial Questionnaire to begin treatment with Jennifer Kimmelman LMFT

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I help motivated people who are experiencing feeling stuck in systems of anxiety, fatigue, stress, loneliness, and depression, shift into systems that usher them into living with more confidence, joy, pleasure, and with a sense of purpose, and do so with a sense of ease, grace, and laughter.

Email *

Name *

Phone Number
*

Are you Located in New York State? *

Yes

Maybe

Other:

Do you have medicare or medicaid?
*

Who can I thank for the referral? *

I am not currently accepting insurance but can offer invoice's for you to submit to your insurance company, will that work for you at this time? *

Yes

Maybe

Are you looking for individual counseling, couples counseling or family counseling? *

What are your goals for therapy? *

I require all new client's to start with weekly session's in the beginning of treatment, will this work for you? *

Yes

Maybe

I offer a 25 minute free phone consultation to gather more information,and to discuss scheduling and fee's prior to our first session. Please leave your availability below. *

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