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Thank you for reaching out—I’m glad you’re here!

This form helps me understand what you’re looking for in therapy, so we can make the most out of your free 15-minute consultation. All information you provide is confidential and will help determine if we’re a good fit to work together. After you submit, I’ll reach out to schedule our consultation call.

Please note: This form should not be used for emergency situations and does not constitute a clinician-client relationship. If you’re experiencing an emergency, please call 911 or go to your nearest emergency room.

Name and pronouns *

Email address *

Best number to contact you *

How did you hear about Practical Resilience or Dr. Randelova? (e.g., Psychology Today, referral, internet search, etc.) *

What kind of therapy are you looking for?

Individual therapy

Couples therapy

EMDR

Trauma recovery therapy

Unsure

Required

Briefly describe what’s bringing you to therapy right now.

The primary reason I'm coming in is: (please select all that apply). *

Due to difficult functioning in my life because of dependence on substances.

I have been accused of being the perpetrator of abuse/violence against another person(s).

Because of an eating disorder

I have been psychiatrically hospitalized in the last year

Because I am court-mandated for treatment

I am involved in litigation and want my clinician to be a part of the ongoing litigation

None apply

Required

Are you planning to use insurance, or do you prefer self-pay?

Insurance

Self-pay

If using insurance, please provide your insurance carrier.

What state will you be in during virtual sessions? *

What’s your general availability for sessions?

How frequently are you hoping to meet for sessions? *

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