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
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First Name
Last Name
Phone Number
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Please enter a valid phone number. An account in the client portal cannot be created without this information.
Email
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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 seeking? (Please note: insurance does not cover couples counseling/therapy, intensives, Emotional Support Animal Services at all.
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Pre-Marital Counseling
Emotional Support Animal Services
Couples Counseling
Family Counseling
Individual Mental Health Therapy
Diagnostic Assessment only
Couples Intensive
Family Intensive
If Couples Counseling, provide your partner's name (Couples should complete consultation forms individually; Failure to have your partner to complete a consultation form on their own, can result in delays.)
First Name
Last Name
What is you main struggle/concern?
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Have you had any therapy/counseling in the past? Was it beneficial?
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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
I have read and understand the Frequently Asked Questions (FAQ) on the website for services.
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Yes
No
I understand that insurance requires a mental health diagnosis and does not cover traditional couples therapy or traditional family therapy.
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Yes
I understand that depending on the type of family therapy that I am seeking, that I may have to pay out of pocket.
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Yes
I'm not seeking family therapy
I understand that couples counseling, ESA letters and intensives are not covered by insurance.
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Yes
I'm not seeking couples counseling, an ESA letter or intensives.
Identify your payment method (Please note: insurance does not cover couples counseling/therapy):
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CareSource
Molina
Anthem/BlueCross BlueShield
Aetna
UnitedHealthcare/Optum/UMR/Oscar
***OpenPath Psychotherapy Collective
CareCredit (acceptable for packages & intensives)
Afterpay (acceptable for packages & intensives)
Self-pay (no insurance)
Are you interested in learning more about adjusted fee rates?
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.
Please verify that you are human
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