bareWell Consulting - Intake Form
Thank you for choosing to work with bareWell Consulting. This form is designed to help you reflect on your goals, challenges, and priorities before our consultation. Your responses will guide our session so we can focus on the areas that matter most to you and your practice.Please answer each question as openly and honestly as you feel comfortable. All responses are confidential and used solely to inform your consultation. You will receive a copy of your submission for your records.
Full Name
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Pronouns
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Licensure Type / State(s) of License
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Licensure/or current professional status e.g., LMFT, AMFT, LCSW, LPCC, Psych Associate, Pre-licensed clinician, student intern, etc.
Preferred Meeting Type
Please Select
In Person
Virtual
*All In person meetings will be held at 1620 5th Ave, Suite 800, San Diego, CA 92101.
Preferred Email Address
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Preferred Phone Number
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Website (if you have one)
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Practice Type
Please Select
Solo
Group
Agency
Other
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What are your primary goals for this consultation? (staying connected with other helpers & healers, learning more, sharpening some existing tools, building community, etc.)
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What would make you feel that our consultation was successful?
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Are you looking for one-time support or ongoing consultation?
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One time Support
Ongoing 1:1 Consultation
Group Consultation
Trainings / Workshops
Topic Areas that feel most aligned to your wants/needs (check all that apply)
Case conceptualizations ('supervision' style, client-centered discussions, alternative perspectives, resourcing, case formulations)
Understanding trauma as more than a set of symptoms, but as a social responsibility, a systemic issue, and neurobiological 'disease' prevention, etc.
Enhance traditional therapeutic models (complex trauma, neurobiological frameworks, harms reduction, somatic, anti oppressive, liberation oriented, etc.)
Demystifying 'taboo' topics in therapy space (sex, kink, infidelity, crime, money, politics, body size, gender, polyamory, race, religion, etc.)
Staying connected & in community with other therapists (combatting isolation, hyper-individualism, scope, ethical issues, clinical policies)
Retention, Rapport, Marketing, & Referrals (networking, relational presence, niche development, pricing, insurance, etc.)
Blending Mentorship/Management/Leadership with Therapeutic Roles
Work-Life Balance & Burnout Prevention (boundaries, self-care, sustainable scheduling)
Other
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Reflections
What is the biggest challenge you’re facing right now in your practice?
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What is your biggest win or success so far in private practice?
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If you imagine your “ideal” practice would look like in 5 years, what does it look and feel like? What populations do you serve, how many hours do you work, are you working alone or in a group, etc.
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Anything else you want or feel would be helpful for me to know? Any other topics not mentioned you would like to spend time focusing on during our time together??
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