Client Intake Form

Hello and Welcome!

I am Inna Zusman, I’m a Licensed Graduate Professional Counselor (LGPC), family and couple therapist, and life & career coach.

Together with my clients, we create relationships where you feel loved, accepted, and fulfilled.

As a mother in a blended family myself, I understand the challenges of cultural differences, parenting conflicts, and life transitions.

Please complete the form below and schedule your free 15-minute consultation — let’s explore how I can help you build connection and peace in your life.

MAKE SURE THAT YOU PUSH BUTTON SUBMIT AT THE END.

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Country of Residence*

Please. choose what type of Therapy or Coaching you are looking for*

State of Residence*

Please., share what is the problem which is bothering you now*

Preferred Contact Method

Insurance Provider*

Good news: I am in-network with select insurance plans.

Waiting times:

Individual therapy: ~ 2–3 months
Couples/Family therapy: ~ 1–2 months

Next step (required):
Please email our administrator at christina@enrichmentwellness.com to be added to the waitlist and to have your profile created.

Helpful to include in your email:

Full name & date of birth
Phone number & state of residence
Insurance plan name and Member ID (front of card)
Preferred modality (in-person/telehealth)
General availability (days/times)
Brief reason for seeking therapy
You’ll receive a reply confirming your spot on the waitlist and any next steps for verification.

Service Urgency Level

Preferred Meeting Times or Availability

Additional Comments or Questions

Please take a moment to review my pricing policy below.

When you’re ready:

Click “Submit” to send me your information.
After submitting, you’ll be redirected to my calendar where you can schedule a free 15-minute consultation call. During this call, we’ll discuss your situation in more detail and explore the best next steps together.

PRICE POLICY

Premium Options
🔸 Evening & Weekend Sessions
Sessions starting after 6:00 PM on weekdays or anytime on weekends are available at a premium rate of + $20 per session.

🔸 Priority Access / Same-Week Appointment
For clients who wish to be seen this week (outside the regular waitlist), a + $30 fee per session applies.

Individual Sessions (60 minutes)
• First 3 sessions – $125 each
• Next 3 sessions – $115 each
• All following sessions – $110 each

Family Sessions (75 minutes)
• First 3 sessions – $130 each
• Next 3 sessions – $125 each
• All following sessions – $120 each

Job Search or Career Consulting (90 minutes) - $150