Seeking AHA Services

Seeking AHA Services

Submit this interest form to seek services with the Aspen Haus Associates, LLC team.
Contact Information

Please use your legal name.
Name*

First NameLast Name
What name do you go by? (nick name)
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Permission to Contact
EmailPhoneMailing Address
MyselfMyself and another party (i.e., marital, family, etc.)My child (17 yrs or younger)My child (18 years or older)Another adult family memberOther
For those seeking services on behalf of another party:

If the other party is a minor, we can only fully explore potential services with the minor's guardian(s).

If the other party is an adult (18 years or older), we cannot make arrangements or discuss details of potential services with anyone other than the prospective adult client. The prospective adult client must contact our office directly to initiate any processes or services.

We can discuss general processes and provide basic information about Aspen Haus with any party that would like more information.
Please complete the remainder of the form for yourself or a party you are elligible to represent.
Previous & Other Professional Services
Previous Client?
YesNo
If 'Yes', which clinician were you a previous client of?
Other Providers

It is important we have the following information.
Please list all current and previous MENTAL HEALTH PROVIDERS from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)*
Please list all current and previous MEDICAL PROVIDERS (MDs, PTs, etc.) from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)*
Please list all current and previous COACHES or OTHER HELPING PROFESSIONALS (Leadership, Life, Couples, etc.) from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)*
YesNo
Referral?
Please tell us how you found our office?*
Who referred you to AHA? (Type 'NA' if none.)*
YesNo
No one specificJenna MountainKimberly GalindoRebecca FaggettChelsey HoganAny AHA ProviderNot Listed
Reason for Seeking Services
Individual CounselingTrauma CounselingEye Movement Desensitization and Reprocessing (EMDR)Marriage or Couples CounselingSex TherapyFamily TherapyGrief CounselingGroup Coaching, Counseling, or Support GroupsConsultation & Evaluation (Non-clinical)Speaking & TrainingCoachingAdolescent (12-17)Child Therapy or Play Therapy (3-12 YO)Custom/Trauma IntensivesIASIS Micro Current NeurofeedbackOther
Marital ChallengesAffair RecoverySexual IssuesIntimacy IssuesPast Wounds or TraumaChildhood AbuseFirst ResponderPTSDDomestic Violence or Partner AbuseSubstance Abuse or AddictionSexual Addiction or Compulsive IssuesPhobiasAnxiety and/or depressionSports PerformanceGrief or LossBereavementChronic Illness or PainBoundariesInfertilityPost-partum ChallengesOther
Marital ChallengesAffair RecoverySexual IssuesIntimacy IssuesPast Wounds or TraumaChildhood AbuseFirst ResponderPTSDDomestic Violence or Partner AbuseSubstance Abuse or AddictionSexual Addiction or Compulsive IssuesPhobiasAnxiety and/or depressionSports PerformanceGrief or LossBereavementChronic Illness or PainBoundariesInfertilityPost-partum ChallengesOther
Please briefly describe reasons for seeking counseling based on the above choices.
Aspen Haus Associates Appointments/Phone Calls will be scheduled by appointment only.

If you are ever in a state of emergency, call 911 or go to the nearest emergency room for emergency services.

Emergency and immediate services are not services provided. The following local resources are alternative options for potential clients who find themselves needing higher levels of care:

EMERGENCY RESOURCES
- Dallas County MHMR 877-283-2121
- Tarrant County MHMR (817) 569-4300
- Collin County MHMR Lifepath Systems (Collin County MHMR) (972) 562-0190
- 24/7 Crisis Text Line Text “NAMI” to 741-741
- National Suicide Prevention Lifeline 1-800-273-TALK (8255) or 1-800-SUICIDE (1-800-784-2433)
- Parkland Hospital Psychiatric Emergency 214-590-8000
- SAMHSA's National Helpline. (800) 662-4357
- The Turning Point Rape Crisis Center Crisis Line 1-800-886-7273
- Dallas Area Rape Crisis Center (972)-641-7273
- Hope’s Door 24-Hr Hotline (Collin County) (972) 276-0057
- Family Place 24-Hr Crisis Line (Dallas County) (214) 941-1991
- Genesis Women’s Shelter Hotline (214) 946-4357
- Carrollton Springs 24 Hr Hotline (972) 885-3795
Do you have a preference on which provider you see or location?
Greater Dallas Area: Richardson, Texas (In Person/Online Services)New Jersey (Counseling/Coaching Online Only)Other state/country (Coaching Only- We can do a lot of work in coaching.)Online Services (Preference)
YesNo
Fees
Sliding Scale or Pro Bono (limited availability)$120-$150/Clock Hour (Newly Provisionally Licensed Clinicians or New Coaches)$150-$185/Clock Hour (Provisionally Licensed Clinicians, Fully Licensed Clinicians, and Coaches)$185-$225/Clock Hour (Fully Licensed Clinicians, Some with Certifications in Specialties, and Experienced Coaches)$200-$350+ (Experienced, Fully Licensed Clinicians with Certified Specializations, and Experienced Coaches)I have no fee concerns.
Prefer In-Person Services (Subject to any Health & Safety Protocols)Prefer Virtual ServicesWilling to attend In-Person Services (Subject to any Health & Safety Protocols)Willing to attend Virtual Services
YesNo
YesNo
Aspen Haus Associates does not currently participate as a provider with insurance plans and is a fee-for-service, or private pay, practice. We are required by law to ask if you have insurance either way.

Please see our website for full explanation.
Availability
Monday Morning (8 am - noon)Monday Afternoon (Noon - 5 pm)Tuesday Morning (8 am - noon)Tuesday Afternoon (Noon - 5 pm)Wednesday Morning (8 am - noon)Wednesday Afternoon (Noon - 5 pm)Thursday Morning (8 am - noon)Thursday Afternoon (Noon - 5 pm)Friday Morning (8 am - noon)Friday Afternoon (Noon - 5 pm)Other
Agreement
I Agree.I Disagree.
I Agree.I Disagree.
Submission
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Signature

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Seeking AHA Services

Contact Information

Permission to Contact

Previous & Other Professional Services

Previous Client?

Other Providers

Referral?

Reason for Seeking Services

Do you have a preference on which provider you see or location?

Fees

Availability

Agreement

Submission