Private Client Consultation/Intake Form 2022 - Shame Free Therapy, Inc. & Rachel Wright, Inc.
If you’re interested in becoming or staying a client (Therapy, Coaching, & Hybrid Therapeutic Coaching), kindly fill out this form and we’ll get back to you as soon as possible.

We offer telehealth to clients worldwide. Our available rates (depending on clinician or coach) are currently between $140-425/session. We do NOT accept insurance.

We have a few spots left on our sliding scale waiting list, but if you're looking for a sliding scale therapist immediately, we highly recommend Open Path Collective & Pride Counseling as an alternative option for lower rates.
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Email *
Name *
Phone Number
Some of our emails have been ending up in Spam folders and potential clients have been unaware that we are trying to reach them! We typically respond to all potential clients within 3-5 business days. If you include your phone number here, we will also send you a text when you have been paired with a coach or clinician!
What kind of sessions are you looking for? *
How often are you wanting to meet with your provider? *
Required
What are the biggest frustrations or challenges in your relationship, sex life, or life in general right now? *
(ex. anxiety, communication, ENM, gender, depression, relationship, trauma, sexuality)
Let's say we work together for 4 months. 4 months from now, what would you like to see be different? What will change? What will be the same? (Go big here, think like you have a magic wand in your hands!) *
How passionate are you about seeing what you wrote above become a reality? *
Not really
Rediculously Committed
If we hop on our call and all determine that we are a good fit to work together, are you ready to fully invest (financially, mentally, + time) into yourself, your life + relationships right now? *
Where are you located? *
State (if in U.S.) — if outside US, country is perfect.
What is your availability? *
Days/times you're typically free to meet
What fee range (per session) is workable for you? *
As a reminder, our available rates (depending on clinician or coach) are currently between $120-400/session.
We will pair you with a clinician or coach that best matches your needs, location (if applicable) and price range. If you have a specific person in mind that you want to work with, please put their name here. *
This could be Rachel or one of the other clinicians within Shame Free Therapy, Inc. or Rachel Wright, Inc. -- If you have no preference right now, you can put that too. {PUTTING THE NAME HERE DOES NOT MEAN YOU WILL GET PAIRED WITH THAT PERSON. THERE ARE LOTS OF FACTORS AT PLAY TO MAKE SURE YOU GET THE BEST CARE POSSIBLE.}
How did we meet/How did you find us? *
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