New Client Screening Form

New Client Screening Form

How exciting that you're ready to begin your healing journey! Please complete the form below and I'll reach out to you via email in 1-2 business days.
Full Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Personal TherapyEMDR Certification ConsultationLMFT SupervisionClinical Consultation
19 to 25 years old26 to 40 years old40 + years old
Have you seen a therapist, counselor or psychologist before?*
Are you familiar with Eye Movement Desensitization and Reprocessing (EMDR)*
Briefly describe what brings you to counseling:*
Briefly describe what you are you hoping to accomplish in therapy.*

Which days and times are you generally available for weekly appointments?*

Alliance CoalBCBSCommunity CareI will be paying out-of-pocket for my sessions. (Hourly rate $200)
How did you hear about me?*
Please Specify who referred you*
After you have submitted the form, I will email you instructions for next steps. I look forward to connecting with you very soon! - Racheal
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