Pre-Consultation Form
Hello! This short form helps ease the initial consultation by clarifying your needs and my availability upfront. It allows me to better understand what you're looking for and determine if we’re a good fit before we connect. If everything aligns, I will reach out to book a call and discuss the next steps. Thank you for considering me for your therapeutic journey.
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Date of Birth
*
Preferred Availability (Times)
*
Please Select
Late Morning (11 AM-1 PM)
Early Afternoon (1 PM-3 PM)
Late Afternoon (3 PM-5 PM)
Early Evening (5 PM-6:30 PM)
I'm Flexible
Note: Early evening/evening (4 PM – 6 PM) time slots are currently on a waitlist.
Preferred Availability (Days)
*
Please Select
Tuesday
Wednesday
Thursday
Friday
Note: Weekend sessions are currently not available.
What type of therapy are you seeking?
*
Individual Therapy
Couples Therapy
EMDR
Session Format Preference
*
In-Person
Virtual
No Preference
How often would you prefer to have sessions?
*
Weekly
Biweekly
Every 3-4 weeks
Not sure
How do you plan of paying for therapy?
*
Insurance (Please note: I do not accept insurance for couples therapy.)
Private Pay (My rate is $140 for individuals/$160 for couples for 50 min sessions)
Unsure
If you would like to use insurance, please provide your insurance type, member ID and group number below so I can verify if I am able to accept your plan.
How did you hear about me? If someone referred you, you’re welcome to let me know their name so I can express my appreciation.
*
What brings you to therapy? You don’t have to share too much—just a few key points to help me see if I’d be the right fit for you.
*
Are there any specific approaches or styles of therapy you're looking for?
*
Anything else you want me to know before our call?
Submit
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