Client Consultation Interest Form

Request Consultation

Our intake coordinator will get in touch with you for a 15-minute consult within 1-2 business days.
Client name*

First NameLast Name
Are you a minor?

YesNo
Name of parent or guardian (if client is a minor)

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
How did you hear about us?
Who is filling out this form?

Client (I am the client age 18 or older)Parent or legal guardian (client is a minor)Referral (I am filling this out for someone else)Other
Are you court mandated for therapeutic services?

YesNo
What time of day is best to call you?

Morning (9:00am - 12:00pm)Afternoon (12:00pm - 4:00pm)Evening (4:00pm - 6:00pm)Other
Mental Health Therapist Preference

Tanya Bingham, LCSW (accepts most major insurances) TELEHEALTHAlicia Price, LCSW (accepts Husky/Medicaid and Anthem BCBS) In-person and Telehealth availableKarla Dunkley, LADC (accepts Husky/Medicaid and United/Optum/Connecticare)Taminesha Holley (CLINICAL INTERN -- Sliding scale only)
Which do you prefer?

In-person (limited availability)Telehealth/virtual
Will you be using insurance? (please check your insurance benefits as these may vary for mental health services.)

YesNo
Primary insurance
Secondary insurance (if applicable)
What kind of therapy have you engaged in previously?

Not applicable/first time in therapyEye Movement Desensitization and Reprocessing (EMDR)Cognitive Behavioral Therapy (CBT)Inpatient Psychiatric TreatmentIntensive Outpatient Program (IOP)Substance RecoveryCouples TherapyFamily TherapyOther
How soon would you like to schedule your first session?

Earliest AvailableWithin the next 1-2 weeksWithin the monthNext month or later
What is the main concern you would like to address in therapy?
Anything else we should know?
Should be Empty:

Request Consultation