Savvy Intuition, LLC
Consultation Form
Please complete all necessary areas. The answers to your questions may be listed on the website.
www.savvyintuitionllc.com/faqs
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number. An account in the client portal cannot be created without this information.
Email
*
An account in the client portal cannot be created without this information.
Date of Birth (therapy consultation only)
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-
Month
-
Day
Year
An account in the client portal cannot be created without this information.
What is your profession?
How did you hear about Savvy Intuition, LLC and/or who were you referred by?
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Are you currently in therapy?
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Yes
No
Other
What type of counseling/therapy are you inquiring of?
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Pre-Marital Counseling
Emergency Couples Therapy
Post-Infidelity Couples Therapy
High-Conflict Couples Therapy
Family Therapy
Multiple
Individual Therapy
Diagnosis only
If Couples Therapy, provide your partner's name ( Partner must complete this form as well)
First Name
Last Name
What is you main struggle/concern?
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How is this concern influencing or causing stress in your life?
Have you had any therapy/counseling in the past? Was it beneficial?
If you have been experiencing symptoms of concern, please describe.
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On a scale of 1 to 7 how important is it for you to work on this difficult situation?
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On a scale of 1 to 7 how ready are you to start therapy and commit to doing the work?
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Please select the type of sessions you would prefer:
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Virtual (zoom, PsychologyToday, Doxy.me video-conferencing, etc.)
In-Person
both
If using insurance as a payment method, which insurance do you have?
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CareSource
Molina
Anthem/BlueCross BlueShield
Aetna
UnitedHealthcare/Optum/UMR/Oscar
***OpenPath Psychotherapy Collective
Self - Pay
Your availability for appointments (please provide timeframes that work for you)
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List your questions here.
Please note: Frequently Asked Questions can be found on the website - www.savvyintuitionllc.com.
I understand that insurance requires a mental health diagnosis.
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Yes
No
I understand that depending on the type of couples therapy or family therapy that I am seeking, that I may have to pay out of pocket.
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Yes
No
I'm not seeking couples/family therapy
I am interested in learning more about your adjusted rates.
Yes
No
I have read and understand the Frequently Asked Questions (FAQ) on the website for services.
*
Yes
No
Please verify that you are human
*
Submit
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