Liberated Light Counseling: Therapy Interest Form
Shout-out to you for taking the brave and bold first step to seek out therapy!

Please take a few minutes to fill out my Therapy Interest Form below which will help determine if we would be a good fit. After you complete this form, I will email you directly to schedule a 15-minute consultation call as a next step.

Thank you and I look forward to connecting with you!

-Aliese Lash, MSW, LICSW
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Today's Date
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Full Legal Name *
Name you prefer to be called *
Gender pronouns *
Email Address *
Phone Number *
How did you hear about Liberated Light Counseling? *
Please give a brief description about why you are seeking out therapy? *
What are your top 3 primary concerns? (Please choose only 3) *
Required
Have you been in therapy before? *
Do you struggle with drug or alcohol overuse? *
Are you currently experiencing domestic violence or interpersonal partner violence? *
Have you experienced suicidal thoughts? *
Have you ever been hospitalized for a mental health crisis? *
What are your top 2 goals for therapy? Or, what 2 areas of your life do you hope will change or improve through your experience in therapy? *
When we first begin meeting for therapy, I highly recommend for folks to begin with weekly sessions. Are you available to meet for weekly 50-minute sessions? *
When do you prefer to meet? (select all that work with your availability) *
Required
How do you plan to pay for therapy? *
Online therapy requires a private space with reliable technology for both the therapist and the client. Please check all that apply for you: *
Required
Where do you currently reside? *
Are you interested in joining Aliese for occasional outdoor/ecotherapy sessions in Boston, MA?
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Is there anything else you would like to share about yourself that may help me to support you in therapy?
If Aliese's current availability schedule is full, would you like to be added to her waitlist (up to 2-4 months)?
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Do you have any other questions or concerns about beginning therapy?
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