Service Inquiry Form

Inquiry Form

Please fill out form and Rachel will contact you to schedule a 15-minute phone consultation.
Full Name

First NameLast Name
Email Address
Rachel uses email for scheduling and administrative purposes only. Please enter a valid email address that you would prefer to be contacted at.
Phone Number
Please enter a valid phone number that you would prefer to be contacted at. This number may be used for phone appointments or administrative purposes.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Permission to Contact:

I give Rachel permission to contact me by phone or email. I use phone calls only for pre-scheduled appointments or to follow up on late cancellations and no-shows. Email: Email is reserved for scheduling and administrative matters only (e.g., appointment coordination, paperwork, or billing questions). Please note that I do not provide clinical support or therapeutic services via phone or email. If you are experiencing a crisis, please contact emergency services or a crisis line in your area.
I am seeking services for:
Who are you seeking services for?
i.e. "myself" or "myself and my spouse" "on behalf of"
How did you find Rachel? Were you referred?
If you list a name, please list how you know them.
Reason for Services:
Briefly describe your reason for seeking services. This may include your primary and secondary concerns and what you would like addressed.
Please check all concerns that are currently present or have previously been challenges in your relationship.

Other
Please list current providers:
If applicable, please list any/all current mental health providers (including counselors, coaches, psychiatrists, etc.).
Location

Rachel currently offers therapy services both online throughout Texas and in-person in Mansfield, TX.

Coaching services are available virtually, no matter where you're located.

Fees

Rachel Henning is a fee-for-service provider. She is not listed on any insurance panels and has opted out as a Medicare provider. Her current therapy fees are listed below:

$200 / Individual/Couples Intake Session (75 minutes)
$185 / Individual/Couples Therapy Assessment Sessions (50 minutes)
$185 / Couples/Sex Therapy Sessions (50 minutes)
$185 / Individual/EMDR Sessions (50 minutes)

Contact Rachel at info@rachelhenning.com for more information on coaching fees.
Please list any fee concerns here:
Please indicate the location(s) where you are comfortable receiving services.
Consent and Acknowledgment:
By submitting and signing this form, you acknowledge that the information provided is accurate to the best of your knowledge. You also consent to being contacted by Anna to initiate services as outlined in this form.
Signature
Should be Empty: