Therapy Interest Form

1
Name
First Name
Last Name
2
Email
example@example.com
3
Where do you live* This field is required.According to the laws related to the practice of counseling, Therapy To A Tea's member's can only provide therapy services within their state(s) of licensure.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
We can work together in three ways* This field is required.Therapy To A Tea's member's are trained to provide trauma-informed care as a baseline. Each member has additional training certifications and licensing according to their specialty and state of licensure. Clients are paired with the clinician who can best meet their needs. If you require immediate emergency assistance, either call '911', or reach the United States National Suicide Prevention Lifeline at 1-800-273-8255.
Online Individual Psychotherapy
Online Relationship Coaching
Online Group Therapy
Online ADHD Coaching
5
What is your gender identity?* This field is required.And your pronouns, if you feel comfortable sharing. If you prefer not to say, you can type 'prefer not to say' or "idk"
6
What is your ethnic identity?* This field is required.If you prefer not to say, you can type 'prefer not to say'
7
Please select the options below that are most related to what is bringing you to therapy.* This field is required.These a few areas that we specialize in. If you do no see your concern/symptoms listed please note them in the box marked 'other'
ADHD
Anti-racism
Anxiousness
Autism
Boundary reshaping
Chronic Pain
Chronic Trauma/ PTSD
Communication Challenges
Depressive Symptoms
Identity Exploration
Life Transition
Relationship Challenges
Self Esteem
Other
8
Please check all that apply* This field is required.What is your experience with therapy, if any?
I have participated in individual therapy before
I have participated in relationship/family counseling before
I have not participated in therapy of any kind before
Other
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How frequently can you commit to meeting for the next 3 months?* This field is required.For therapy to be effective there is a recommended frequency that one meets for therapy sessions.
Weekly
Bi-Weekly
10
What days and times work best for telehealth appointment?* This field is required.This information is important to assess most appropriate fit.
11
Anything else you want to share?The next set of questions are closed choice. If you think of something after completing this form , we encourage you to email us at admin@therapytoatea.com
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Are you ready to engage in your mental wellness journey actively and deliberately?* This field is required.You are the key to the success of your wellness journey! Starting therapy is going to require you to work alongside your therapist inside and out of the scheduled sessions, to make progress toward your goals. There are no magical or instant results.
YESNO
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Are you prepared to read all documents and asking any questions about the contents before signing them and before your first appointment?* This field is required.The documents provided to you will have important information about the expectations and agreements between you and Therapy To A Tea. The documents will include information appointments, fees, communication, benefits and risks.
YESNO
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Are you prepared to invest your time into your wellness journey on a weekly or biweekly meeting schedule?* This field is required.The frequency of sessions depends of the nature of the goals set, the experience of symptoms, and the therapy modalities applied.
YESNO
15
Insurance reimbursement documentation must include a diagnosis if you use your FSA/HSA card or request a superbill?* This field is required.Therapy To A Tea is out of network for all insurances in NY, GA, FL. Therapy To A Tea is in network with only Cigna in Washington, DC. I understand how using insurance contributes to the medical industrial complex?
Yes, I understandNo, I do not understand
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You must be seen for six consistent weeks before any Emotional Support Animal, FMLA or Gender-affirming letter can be provided* This field is required.Documentation such as the ones listed require the mental health professional to speak to your unique experience.
Yes, I understandNo, I do not understand
17
Therapy To A Tea charges for no-call/ no-shows* This field is required.As you would at a doctors or dentist office
Yes, I understand No, I do not understand
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How did you hear about us?* This field is required.Please scroll to view all of your options
Please Select
Friend
Insurance website
Mental Healthcare Professional referral
Podcast
Social Media
Therapy For Black Girls
TherapyToaTea.com
Other (Please specify...)
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