Pre-Screen Form

1
Please Read Before Completing This Form:

We are licensed to practice in the state of Florida only.

We are a fully self-pay practice and not in network with any insurance companies.

Our rate is $165 per session; sessions are for 45 minutes.

An introductory call must be completed prior to scheduling your first session.

The introductory (consultation) call is not a therapy session and does not establish a therapist-client relationship.

We are completely virtual and all services are provided online (no in-person services are available).

If you need help during our intake process, please call 954-613-9414 and leave a voicemail with your name, phone number, and request for help.
2
How did your hear about us?* This field is required.
Google Search
Family or Friend
Online Directory (Therapy for Black Girls, Psychology Today, etc.)
Another therapist or healthcare professional
Open Path Collective
Podcast
3
Are you completing the form for yourself or someone else? * This field is required.
Myself
Someone else
4
Your Information* This field is required.
Legal First Name
Legal Last Name
Date Of Birth
Phone Number
Your Email Address
Your Place of Residence
5
Consent* This field is required.
This is a safe number.
SoundMind Wellness can leave a voicemail at the number provided above.
I agree to check the email provided above regularly.
6
We assess the safety of each potential client:* This field is required.Please select yes or no for each question below:
No
Yes
Is there any current risk for suicide and/or homicide?
No
Yes
Is there any current risk for domestic or partner violence?
7
Briefly tell us why you are seeking services at this time?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
8
NEXT STEPS:

You will be redirected to our scheduling page to schedule the introductory call.

We will review your responses and scheduling request.

You will receive an email from us with more information.

If you do not respond within 7 days of us emailing you, we will assume you are no longer interested and will close out your request.
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