Client Inquiry Form
Thank you for reaching out. This form helps us determine your needs and match you with the right therapist. Please complete the questions below. We will contact you within 24–48 hours.
Client Information
Client Name:
*
First Name
Last Name
Age:
*
Gender:
Race/Ethnicity
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Session Information
Who will be receiving therapy?
*
Myself
My Child
Couple
Family
Are you or the person receiving services currently involved in the court system? (Examples: CPS involvement, family court, probation, legal case, required therapy)
*
Yes
No
If yes, please briefly explain:
At this time, services are Private Pay Only.
Session fee: $125 per individual session. $175 for family or couples. $300 for court involved cases.
Are you comfortable with private pay?
Yes
No
I have questions
What questions do you have about the item above?
Sliding Scale Option:
A limited number of sliding scale spots may be available upon proof of financial need.
Would you like to be considered for the sliding scale?
Yes
No
I have questions
What questions do you have about the item above?
We are currently providing services virtually only.
Are you comfortable with telehealth sessions?
Yes
I prefer in-person (I understand this is not available at this time)
Therapy Goals
What would you like to work on in therapy? (Check all that apply or add your own.)
*
Anxiety / Stress
Depression / Low Mood
Trauma / Past Experiences
Family Conflict
Relationship Concerns
Parenting Support
Emotional Regulation
Childhood Experiences / Attachment
Identity Exploration
Grief / Loss
Other
If other was selected, please briefly explain.
What therapist qualities are important to you? (Choose any that matter to you.)
Warm and Supportive
Direct and Straightforward
Structured and Goal-Focused
Gentle and Calming
Provides Practical Tools and Skills
Challenges and Encourages Growth
Bilingual (English/Spanish)
LGBTQ+ Affirming
Trauma-Informed
Other
If other was selected, please briefly explain.
Is there anything else you’d like us to know before we contact you?
Scheduling
What date would you like to begin services?
*
What days/times work best for your sessions? (Example: Mondays after 4pm, weekday mornings, weekends, etc.)
How did you hear about us?
*
Please Select
Searched Online
Therapy Website, i.e. Psychology Today
Friend/Family Member
Social Media
Other
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