Contact Form

Welcome to Quiet Contemplation

New Client Information
Please read before you continue:
I provide individual therapy only for people who live in states where I am licensed. I am currently licensed in Florida and Minnesota. This means I can only offer therapy services to people living in these states at the time of service.
I accept insurance only for Florida residents at this time. I am working toward becoming paneled with insurance in Minnesota, but this is not active yet
What name do you go by?

First NameLast Name
Date of Birth

MonthDayYear
Phone Number
Best number to reach you
E-mail
For appointment updates and helpful resources
Where are you currently living? (State must match where you will receive services)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
You must live in a state where I am licensed at the time of service. If you live outside of Florida or Minnesota, you may still complete this form but may team contact you about options like referral resources or coaching.
Emergency Contact (please share someone we can reach in case of emergency)

First NameLast Name
Emergency Contact Phone Number
What brings you here today?
Please choose the type of support you’re interested in:
Please note: individual therapy is only available to folks residing in Florida and Minnesota
Insurance Information

If you plan to use insurance, this helps us prepare before your first session.
Insurance Eligibility Right Now

Florida | Yes | Accepting insurance
Minnesota | No | Working toward paneling
All other states | No | Not currently available
What type of insurance coverage do you have?

No insurance / self-payPrivate health insurance (e.g. BCBS, UHC, Aetna)Medicaid / state-based insuranceOther (please specify)
Insurance Provider Name
Example: Blue Cross Blue Shield
Authorization & Consent

Consent and Acknowledgment
By submitting this form, I confirm the information I’ve shared is accurate and complete. I understand that Quiet Contemplation will use this information to support scheduling and communication. My information will not be shared outside Quiet Contemplation without my permission.

I understand that submitting this form is for intake and scheduling purposes only and does not create a therapist-client relationship. Therapy services begin only after consent is completed and services are confirmed.

If I am experiencing a mental health emergency, I understand that this form is not monitored in real time and I should contact local emergency services or a crisis hotline (211)
Terms and Conditions

I understand and agree
Thank you for taking the time to complete this form.

Thank you for submitting your info. Because of licensing requirements I can only offer therapy for Florida and Minnesota residents at this time. If you are outside of Florida I will let you know next steps including referral options.

Once you click submit, our team will review your information and reach out within 48 business hours.

If you need support sooner or have questions in the meantime, you are welcome to text our support line at 727-379-2248 to connect with Ashley, our Operations Manager. We are so glad you are here.
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Welcome to Quiet Contemplation

What brings you here today?

Insurance Information

Authorization & Consent